Clinical Medical Assisting: A Professional, Field Smart Approach to the Workplace Michelle E. Heller, Lynette M. Veach Vice President, Career and Professional Editorial: Dave Garza Director of Learning Solutions: Matthew Kane Senior Acquisitions Editor: Rhonda Dearborn Managing Editor: Marah Bellegarde
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Printed in the United States 1 2 3 4 5 XX 10 09 08
Above all, I dedicate this book to God—for through Him all things are possible; and to my husband Kevin and my children—Erin, Megan, and Kevin Ryan—I love you all! Michelle Heller
I wish to dedicate this first edition to my children, Christopher and Kelly, for their love, support, encouragement, understanding, and patience. Lynette M. Veach
Br ieF CHAPTER 1 CHAPTER 2 CHAPTER 3 CHAPTER 4 CHAPTER 5 CHAPTER 6 CHAPTER 7 CHAPTER 8 CHAPTER 9 CHAPTER 10 CHAPTER 11 CHAPTER 12 CHAPTER 13 CHAPTER 14 CHAPTER 15 CHAPTER 16 CHAPTER 17 CHAPTER 18 CHAPTER 19 CHAPTER 20 CHAPTER 21 CHAPTER 22 CHAPTER 23 CHAPTER 24 CHAPTER 25 CHAPTER 26 CHAPTER 27 CHAPTER 28 CHAPTER 29 CHAPTER 30 CHAPTER 31 CHAPTER 32 CHAPTER 33 CHAPTER 34 CHAPTER 35
CONTENTS
Journey to Professionalism Organization and Time Management in the Medical Office The Complete Medical Record and Electronic Charting Fundamentals of Documentation Conducting a Patient Interview and Developing a Medical History Developing In-Office Screening Skills Conducting Telephone Screenings Assisting Patients with Special Needs Patient Education Principles of Infection Control and OSHA Standards Basic Vital Signs and Measurements The Physical Exam Eye and Ear Exams and Procedures Gastrointestinal Evaluations and Procedures Cardiovascular Exams and Procedures Pulmonary Examinations and Procedures Women’s Health Issues: Obstetrics and Gynecology Urology and Male Reproductive Examinations and Procedures Evaluation and Care of the Pediatric Patient Evaluation and Care of the Geriatric Patient Orthopedics, Rehabilitation, and Physical Therapy Medical and Surgical Asepsis Instrument Identification and Tray Setups Assisting with Minor Office Surgeries and Wound Care Procedures Fundamentals of the Medical Laboratory Collecting the Blood Sample Urinalysis Hematology and Coagulation Studies Microbiology Clinical Chemistry and CLIA Waived Rapid Tests Diagnostic Imaging Fundamentals of Pharmacology Dosage Calculations Administration of Parenteral Medications Urgent Care and Emergency Procedures
1 18 37 62 84 106 126 149 176 188 222 257 277 301 320 347 372 406 426 455 474 505 526 552 589 617 652 679 701 732 759 778 820 835 883
C O N T E N T S List of Procedures Preface About the Authors Acknowledgments How to Use this Book How to Use the StudyWARE Software CD-ROMs Supplements At-a-Glance
CHA P TE R 1 Journey to Professionalism ❖ Professionalism and the Clinical Medical Assistant
xxiv xxvii xxx xxxi xxxii xxxiv xxxvi
1 3
A Higher Degree of Professionalism
❖ Developing Your Professional Persona
4
The Internal Journey The External Journey
CHA P TE R 2 Organization and Time Management in the Medical Office ❖ Becoming Organized While You Are in School
18 20
Taking Charge of the Educational Process Getting the Most Out of Your Study Time Preparing for Competency Testing
❖ Getting Acclimated to Your New Work Environment
22
Locating Where Items Are Stored Interviewing Providers Who You Will Be Working With
❖ Setting Up Your Workstation and the Clinical Area Supplies and Equipment for the Work Environment
23
CONTENTS
❖
v
Organizing Patient Exam Rooms Setting Up a Pending File Workstation
❖ Daily Procedures that Clinical Staff Members Perform
26
Opening Procedures for the Clinical Medical Assistant Closing Procedures for the Clinical Medical Assistant Reviewing and Maintaining Patient Charts Creating and Implementing Daily Task Lists Working the Floor of a Medical Office
❖ Clinical Assisting and Time Management Issues ❖ Performing Routine Maintenance on Clinical Equipment
31
PROCEDURE 2-1 Performing Routine Maintenance on Clinical Equipment
33
CHA P TE R 3 The Complete Medical Record and Electronic Charting ❖ The Medical Record
31
37 39
Important Uses of the Medical Record
❖ Medical Records Formats
40
Source-Oriented Medical Record (SOMR) Problem-Oriented Medical Record (POMR) Combining Formats
❖ Contents of the Medical Record
40
Administrative Information in a Medical Record Clinical Information in a Medical Record
❖ Creating and Maintaining the Medical Record
51
Maintaining the Medical Record Documenting in the Medical Record Electronic Medical Records (EMRs)
❖ Laws that Affect the Medical Record
54
The Health Insurance Portability and Accountability Act of 1996 (HIPAA)
❖ Ownership, Retention, and Disposal of Medical Records
56
Fees Associated with Copying of Medical Records Retention of Medical Records Disposal of Medical Records
PROCEDURE 3-1 Create and Maintain the EMR Using SynapseEHR 1.0 Software
CHA P TE R 4 Fundamentals of Documentation ❖ Guidelines for Documenting in the Patient’s Chart Documenting for Legal Success General Guidelines for Documenting in the Patient’s File The Use of Medical Abbreviations in Chart Entries Documenting Chief Complaints and Progress Notes Documenting Laboratory Procedures Documenting In-Office Procedures Documenting Medications Documenting Prescriptions Documenting Patient Education Sessions Documenting Telephone Calls Documenting Referrals Documenting Precertifications
58
62 64
vi
❖
CONTENTS
Documenting Outside Procedures Documenting Hospital Admissions
❖ Making Corrections or Addendums to Chart Notes ❖ Documenting and Sending Faxes ❖ Writing and Sending E-Mails
CHA P TE R 5 Conducting a Patient Interview and Developing a Medical History ❖ Therapeutic Communication
78 80 81
84 86
The Use of Body Language and Therapeutic Communication “Touching” in a Therapeutic Environment
❖ Stages of the Patient Interview Stage Stage Stage Stage
87
I: Preparation II: Greeting and Introduction III: Body of the Interview IV: Conclusion
❖ Incorporating Effective Interviewing Techniques
91
Effective Questioning Techniques Ineffective Questioning Techniques Effective Listening Techniques
❖ Tools Used to Collect Medical History Information ❖ Types of Health Histories ❖ The Comprehensive Medical History
92 95 96
Personal Medical History Family Medical History Social History
PROCEDURE 5-1 Conducting a Patient Interview and Completing a Patient History Form
CHA P TE R 6 Developing In-Office Screening Skills ❖ Establishing Boundaries ❖ The Role of the Medical Assistant during In-Office Screenings
102
106 107 107
Developing the Chief Complaint Documenting Findings from the Initial Screening
❖ Improving Anticipation Skills and Following Office Protocol ❖ The Provider’s Role during the Assessment Process ❖ The Follow-Up Appointment/Progress Notes
117
PROCEDURE 6-1 Conduct and Record Results from an In-Office Screening
120
PROCEDURE 6-2 Conduct a Follow-Up Interview and Develop a Progress Note
122
CHA P TE R 7 Conducting Telephone Screenings ❖ Customer Service and Telecommunications
118 118
126 128
Basic Rules of Etiquette
❖ Triaging ❖ Telephone Medicine Telephone Screenings
130 130
CONTENTS
❖
vii
Legalities of Telephone Medicine Desired Traits of a Good Telephone Screener The Medical Assistant’s Role during Telephone Screenings Summary of Dos for Telephone Screenings
❖ Screening Patient Test Results
137
Handling Critical Lab Results Calling Patients with Test Results
❖ ❖ ❖ ❖
Calling In Prescriptions
140
Sending Faxes
140
Electronic Mail (E-Mail)
141
Working with TDD or TTY Devices
142
Scheduling Appointments for Patients with Limited English
❖ Video Conferencing
142
PROCEDURE 7-1 Perform a Telephone Screening
143
PROCEDURE 7-2 Screen and Follow Up on Test Results (Determine the Order of Prioritization)
144
CHA P TE R 8 Assisting Patients with Special Needs ❖ Legal Issues and the Special Needs Patients
149 151
Laws for the Hearing Impaired or Deaf Patient Laws Assisting the Sight Impaired or Blind Patient Accessible Design Standards for Persons with Physical Disabilities Laws for Patients with Limited English Proficiency (LEP)
❖ Working with Patients with Special Needs
154
Cultural Diversity in Health Care Working with Sight Impaired and Blind Patients Working with Hearing Impaired and Deaf Patients Working with Older Adults Working with the Pediatric Patient Working with Physically Disabled Patients Working with Patients Who Are Mentally Impaired
PROCEDURE 8-1 Effectively Communicate with Patients from Different Cultures
169
PROCEDURE 8-2 Effectively Communicate with Sight Impaired or Blind Patients
170
PROCEDURE 8-3 Effectively Communicate with Hearing Impaired or Deaf Patients When an Interpreter Is Present
172
PROCEDURE 8-4 Effectively Communicate with a Hearing Impaired or Deaf Patient Who Speech Reads
173
CHA P TE R 9 Patient Education ❖ Adult Education Principles ❖ Settings and Procedures
176 177 179
Tools for Education
❖ Communication
180
Verbal Communication Nonverbal Communication
❖ Stimulating Patient Compliance
182
viii
❖
CONTENTS
❖ Topics for Education
182
Self-Examinations Screening Examinations Educating Patients about Their Medication
❖ Conducting Educational Sessions over the Telephone ❖ Identifying Community Resources for the Patient PROCEDURE 9-1 Provide Instruction for Health Maintenance and Disease Prevention and Identify Community Resources That Will Assist the Patient
CHAP TER 1 0 Principles of Infection Control and OSHA Standards ❖ The Infection Process ❖ The Chain of Infection
183 183 184
188 190 190
Causative Agents Reservoir Portal of Exit Mode of Transmission Portal of Entry Susceptible Host
❖ Environmental Requirements for Microorganisms ❖ Stages of Infection
193 193
Invasion and Multiplication Stage Incubation Stage Prodromal Stage Acute Stage Declining Stage Convalescent Stage
❖ The Body’s Mechanisms of Defense
194
The Process of Inflammation The Immune System The Immune Response Types of Immunity Immunizations Types of Vaccines
❖ Infection Control
197
Medical Asepsis
❖ Universal Blood and Body Fluid Precautions
200
Standard Precautions Transmission-Based Precautions
❖ Commonly Transmitted Bloodborne Diseases
201
AIDS Hepatitis
❖ OSHA Regulations
204
Bloodborne Pathogen Standard Blood, Body Fluids, and OPIM Exposure Determination Exposure Control Plan The Biohazard Label
❖ Exposure to Hazardous Chemicals Chemical Hygiene Plan
212
CONTENTS
❖
ix
❖ Safeguards in the Educational Environment
215
PROCEDURE 10-1 Perform Medically Aseptic Handwashing
216
PROCEDURE 10-2 Perform an Alcohol-Based Hand Rub
217
PROCEDURE 10-3 Remove Contaminated Gloves
218
CHAP TER 1 1 Basic Vital Signs and Measurements ❖ Introduction to the Patient
222 223
Screening the Patient The Patient Intake
❖ Height and Weight
224
BMI or Body Fat Percentage
❖ Vital Signs
226
Temperature Pulse Respiration Blood Pressure Pain Assessment Pulse Oximetry
PROCEDURE 11-1 Obtain the Height and Weight of an Adult Patient
242
PROCEDURE 11-2 Obtain an Oral Body Temperature
244
PROCEDURE 11-3 Obtain an Aural Body Temperature
245
PROCEDURE 11-4 Obtain an Axillary Body Temperature
247
PROCEDURE 11-5 Obtain a Temporal Artery Body Temperature
248
PROCEDURE 11-6 Obtain a Radial Pulse Rate and Respiration Rate
249
PROCEDURE 11-7 Obtain an Apical Pulse Rate
251
PROCEDURE 11-8 Obtain a Blood Pressure Measurement Using the Palpatory Method
252
CHAP TER 1 2 The Physical Exam ❖ The Examination Room
257 258
Preparation of the Exam Room Instruments for Examination
❖ Patient Preparation ❖ Patient Positioning and Draping ❖ Patient Assessment
260 262 264
Completing the Visit
PROCEDURE 12-1 Prepare the Examination Room
270
PROCEDURE 12-2 Position and Drape the Patient
271
PROCEDURE 12-3 Assist with the General Physical Examination
273
CHAP TER 1 3 Eye and Ear Exams and Procedures ❖ Types of Providers Who Specialize in Treating Eye Disorders ❖ Patient Screening for the Eyes ❖ Visual Acuity Testing Screening Distance Visual Acuity
277 278 279 279
x
❖
CONTENTS
Screening Near Visual Acuity Color Vision Screening Contrast Sensitivity Testing Instruments for Vision Testing
❖ ❖ ❖ ❖ ❖ ❖ ❖
Eye Instillation
284
Eye Irrigation
285
The Ear
285
Types of Providers Who Treat Conditions of the Ear
286
Patient Screening for the Ear
286
Hearing Defects
286
Hearing Acuity
287
Gross Hearing Screening Tuning Fork Screening Audiometry Tympanometry
❖ Ear Instillation ❖ Ear Irrigation
290
PROCEDURE 13-1 Snellen Chart Visual Acuity Testing
291
PROCEDURE 13-2 Screen Near Visual Acuity
292
PROCEDURE 13-3 Ishihara Test for Color Vision
293
PROCEDURE 13-4 Eye Instillation
294
PROCEDURE 13-5 Eye Irrigation
295
PROCEDURE 13-6 Ear Instillation
297
PROCEDURE 13-7 Ear Irrigation
298
CHAP TER 1 4 Gastrointestinal Evaluations and Procedures ❖ Types of Providers Who Specialize in Treating GI Disorders ❖ Patient Screening for the GI System ❖ GI Examinations Performed in the Medical Office
290
301 303 303 303
Abdominal Pain Rectal Exams and Various Types of Fecal Testing
❖ Diagnostic Procedures
306
Screening Colonoscopy
❖ Nutrition
308
Nutritional Guidelines Health Benefits from the Food Groups Educating Patients about Good Nutrition
❖ Exercise ❖ Eating Disorders
311
PROCEDURE 14-1 Perform a Fecal Occult Blood Test
313
PROCEDURE 14-2 Instruct the Patient on How to Collect a Fecal Specimen
315
PROCEDURE 14-3 Assist with a Flexible Sigmoidoscopy
316
CHAP TER 1 5 Cardiovascular Exams and Procedures
312
320
❖ Types of Providers Who Specialize in Treating Cardiovascular System Diseases and Disorders
322
CONTENTS
❖ ❖ ❖ ❖ ❖
❖
xi
Patient Screening for the Cardiovascular System
322
Anatomy of the Heart
322
The Heart’s Electrical Conduction System
323
The Cardiac Cycle
323
Types of EKG Units
324
Single-Channel EKG Unit Multichannel EKG Unit Automated EKG Units Telephone Transmission Facsimile
❖ EKG Equipment and Supplies
326
EKG Paper Electrodes and Electrolyte Care and Maintenance
❖ EKG Lead Placement
328
Standard Limb Leads Augmented Leads Chest or Precordial Leads Lead Marking Codes
❖ ❖ ❖ ❖ ❖ ❖
Rhythm Strip
331
Standardizing the EKG
331
Performing the Resting 12-Lead EKG
331
Mounting the EKG Tracing
332
Artifacts
332
Cardiac Arrhythmias
332
Premature Atrial Contractions Paroxysmal Atrial Tachycardia Atrial Fibrillation Premature Ventricular Contractions
❖ Defibrillation ❖ Miscellaneous Cardiac Diagnostic Testing
336 337
Holter Monitor Treadmill Stress Test Dobutamine Stress Test Echocardiography Cardiac Catheterization Noninvasive Heart Scan
PROCEDURE 15-1 Perform a Standard 12-Lead Electrocardiogram with a Multichannel Unit
342
PROCEDURE 15-2 Apply the Holter Monitor
344
CHAP TER 1 6 Pulmonary Examinations and Procedures ❖ Types of Providers Who Specialize in Treating Pulmonary Disorders ❖ Respiratory Health Screening Questions
347 349 349
Respiratory Examinations
❖ Factors That May Increase the Patient’s Risk for Respiratory Disease Smoking Environmental Hazards Contagious Infections
350
xii
❖
CONTENTS
❖ Diagnostic Testing
352
Radiological Exams Pulmonary Function Testing Peak Flow Testing Pulse Oximetry Testing Laboratory Tests TB Skin Testing Sleep Apnea Studies
❖ Medication Inhalation Therapy
361
Nebulizers Inhalers
❖ Oxygen Administration
363
Legal Issues to Consider When Administering Oxygen
PROCEDURE 16-1 Perform a Spirometry Test
364
PROCEDURE 16-2 Perform Pulse Oximetry
365
PROCEDURE 16-3 Obtain a Sputum Specimen and Prepare a Smear
366
PROCEDURE 16-4 Administer a Nebulizer Treatment
368
CHAP TER 1 7 Women’s Health Issues: Obstetrics and Gynecology
372
❖ Types of Providers Who Specialize in Treating Diseases and Disorders of the Female Reproductive System
❖ Patient Screening for the Female Reproductive System ❖ Gynecology ❖ The Menstrual Cycle
374 374 374 374
Menopause
❖ The Gynecological Exam
378
General Medical Assisting Duties Mammography and Breast Exam The Pelvic Exam Bimanual Pelvic Exam Rectal Exam
❖ ❖ ❖ ❖
Gynecological Diagnostic Tests and Procedures
384
Sexually Transmitted Diseases
384
Obstetrics
387
Prenatal Care
387
The Initial or First Prenatal Exam Return Prenatal Visits
❖ Prenatal Diagnostic Tests and Procedures
393
Ultrasound Amniocentesis
❖ Pregnancy Complications ❖ Labor and Delivery ❖ Postnatal or Postpartum Period
396 396 396
Six Week Postpartum Visit
PROCEDURE 17-1 Assist with a GYN Exam and Pap Test
399
PROCEDURE 17-2 Instruct the Patient in Breast Self-Examination
401
PROCEDURE 17-3 Assist with the Prenatal Exam
402
CONTENTS
CHAP TER 1 8 Urology and Male Reproductive Examinations and Procedures
❖
xiii
406
❖ Types of Providers Who Specialize in Treating Diseases and Disorders of the Urinary and Male Reproductive System
❖ Patient Screening for the Urinary System ❖ Diagnostic Testing
407 408 408
Laboratory Analysis Cystoscopy Intravenous Pyelography (IVP) Percutaneous Suprapubic Bladder Aspiration
❖ Treatments Involving the Urinary Structures
412
Extracorporeal Shock Wave Lithotripsy Urethral Dilatation Dialysis Kidney Transplant
❖ Patient Screening for the Male Reproductive System
416
Provider Examination Testicular Self-Examination
❖ Diagnostic Testing Associated with the Male Reproductive System
418
Transrectal Ultrasound (TRUS) Vasography Biopsy
❖ Lab Work Associated with Male Reproductive Organs ❖ Common Procedures Performed Involving Male Reproductive Organs
418 419
Vasectomy TURP Circumcision
❖ Erectile Dysfunction
420
PROCEDURE 18-1 Urinary Catheterization
422
CHAP TER 1 9 Evaluation and Care of the Pediatric Patient ❖ Pediatric Age Classifications ❖ Age-Appropriate Communication ❖ Infant/Toddler Measurements
426 428 428 429
Height Weight Circumferences Pediatric Vital Signs
❖ Pediatric Development
434
Motor Development Sensory Development Language Development
❖ Screenings
436
Visual Auditory
❖ Vaccinations Schedules Controversies
437
xiv
❖
CONTENTS
❖ ❖ ❖ ❖
Pediatric Injections
440
Blood Screenings of the Newborn
441
Circumcision
442
Adolescent Care
442
Height/Weight Puberty Sports and Athletics
❖ Behavioral and Mental Health Issues
444
Depression Eating Disorders Abuse Suicide
PROCEDURE 19-1 Obtain the Height/Length and Weight of an Infant
446
PROCEDURE 19-2 Obtain the Temperature of an Infant or Young Child
447
PROCEDURE 19-3 Perform a PKU on a Newborn
449
PROCEDURE 19-4 Perform a Pediatric Injection
451
CHAP TER 2 0 Evaluation and Care of the Geriatric Patient ❖ The Process of Aging ❖ Cognitive Functioning and Development
455 456 458
Areas of Cognition Affected by Aging Disease Processes Alzheimer’s and Dementia
❖ Examination/Screening of the Geriatric Patient
462
Physical Screening Vital Signs The Frail Senior
❖ Common Diseases of the Geriatric Patient
464
Arthritis Diabetes Osteoporosis Parkinson’s Disease Cerebrovascular Accident (CVA)
❖ Societal Issues and Concerns
468
Senior Care and Senior Abuse Depression Nutrition and Hydration Death and Dying
CHAP TER 2 1 Orthopedics, Rehabilitation, and Physical Therapy
474
❖ Types of Providers Who Specialize in Treating Diseases ❖ ❖ ❖ ❖
and Disorders of the Musculoskeletal System
476
Patient Screening for the Musculoskeletal System
476
Assisting with the Orthopedic Exam
476
Common Diagnostic Procedures Performed on Orthopedic Patients
477
Strains, Sprains, Fractures, and Dislocations
477
Casts
CONTENTS
❖
xv
Other Immobilization Devices
❖ Alternative Treatment Methods
483
Orthopedic Surgical Procedures Treatment Options for Arthritis
❖ Rehabilitation
483
Physical Therapists and Occupational Therapists Thermal Modalities Ultrasound Hydrotherapy Exercise Electrical Stimulation of Muscles
❖ Ambulatory Assistive Devices
489
Canes Crutches Walkers Wheelchairs
PROCEDURE 21-1 Administer Heat Therapy Treatments
494
PROCEDURE 21-2 Administer Cold Therapy Treatments
496
PROCEDURE 21-3 Instruct a Patient to Use a Cane
498
PROCEDURE 21-4 Instruct a Patient to Use Axillary Crutches
499
PROCEDURE 21-5 Instruct a Patient to Use a Walker
500
PROCEDURE 21-6 Assist a Patient from the Wheelchair to the Exam Table and Back to the Wheelchair
501
CHAP TER 2 2 Medical and Surgical Asepsis ❖ Asepsis ❖ Care and Maintenance of Surgical Instruments
505 506 507
Soaking Instruments Sanitizing Instruments Lubricating Instruments Inspecting Instruments Disinfecting Instruments
❖ Sterilization Techniques
512
Dry Heat Sterilization Gas Sterilization Chemical Sterilants Autoclaving
PROCEDURE 22-1 Sanitization and Lubrication of Instruments
518
PROCEDURE 22-2 Chemical Disinfection of Instruments
519
PROCEDURE 22-3 Wrap Items for Sterilization and Operate an Automated Autoclave
521
CHAP TER 2 3 Instrument Identification and Tray Setups
526
❖ Types of Instruments Used in Minor Surgery
528
Identifying the Parts of a Surgical Instrument Categories of Instruments
❖ Solutions and Supplies Used for Minor Surgeries Common Solutions Used in Minor Surgery
535
xvi
❖
CONTENTS
Common Supplies Used in Minor Surgery Common Anesthetics Used in Minor Surgery Suture Materials Other Supplies Used to Close the Skin
❖ Types of Procedures Performed in the Medical Office/Tray Setups
541
Procedures That Require No Special Equipment Procedures That Require the Use of Special Equipment, Lasers, or Chemicals
PROCEDURE 23-1 Apply Skin Closures
546
PROCEDURE 23-2 Suture or Staple Removal
548
CHAP TER 2 4 Assisting with Minor Office Surgeries and Wound Care Procedures ❖ Developing a Sterile Conscience ❖ Patient Safety Considerations ❖ Preparing for Office Surgeries
552 554 554 555
Setup Procedures Once the Patient Enters the Surgical Suite
❖ Performing a Surgical Handwash and Applying Surgical Attire ❖ Assisting the Physician Before and During the Procedure
561 562
Pre-Procedure Tasks During the Procedure At the Conclusion of the Surgery
❖ Wound Care
564
Stages of Wound Healing Today’s Wound Care Philosophy Types of Dressings Types of Bandage Material Wound Care Alternatives
PROCEDURE 24-1 Perform a Surgical Handwash and Apply Surgical Gloves
570
PROCEDURE 24-2 Prepare the Patient’s Skin for the Surgical Procedure Using a One-Step Scrub
573
PROCEDURE 24-3 Disinfect a Surgical Tray and Place a Sterile Barrier on the Tray
574
PROCEDURE 24-4 Open Sterile Items and Place Them on the Sterile Field
576
PROCEDURE 24-5 Set Up a Complete Sterile Tray and Pour a Sterile Solution 578 PROCEDURE 24-6 Apply Surgical Attire
581
PROCEDURE 24-7 Remove an Old Dressing, Irrigate the Wound, and Apply a New Dressing
584
CHAP TER 2 5 Fundamentals of the Medical Laboratory ❖ Rationale for Laboratory Tests ❖ Laboratory Regulations
589 591 592
Clinical Laboratory Improvement Amendment (CLIA ‘88) Testing Categories
❖ Implications of CLIA ‘88 for the Medical Assistant ❖ Other Accreditation Options for POLs ❖ Classifications of Laboratories
594 594 594
CONTENTS
❖
xvii
Reference Laboratory Hospital Laboratory Physician’s Office Laboratory (POL) Point-of-Care Testing (POCT) Procurement Station
❖ Laboratory Departments
595
Urinalysis Department Hematology Department Clinical Chemistry Department Microbiology Department Immunology Department Cytology Department Histology Department Blood Bank
❖ ❖ ❖ ❖ ❖ ❖ ❖
Laboratory Personnel
597
Quality Control
597
Quality Assurance
599
Proficiency Testing
600
Safety in the Laboratory
600
Hazards
601
Processing Requests for Laboratory Tests
601
The Laboratory Requisition The Laboratory Report
❖ Preparing the Patient for Laboratory Testing ❖ General Guidelines for Specimen Collection, Handling, and Transport
606 606
Specimen Collection
❖ The Microscope
608
Parts of the Microscope Care and Maintenance Types of Microscopes
❖ The Centrifuge
609
Operating the Centrifuge
PROCEDURE 25-1 Review and Report Laboratory Results
611
PROCEDURE 25-2 Specimen Collection for Offsite Testing
611
PROCEDURE 25-3 Use the Microscope
613
CHAP TER 2 6 Collecting the Blood Sample ❖ Why Do We Collect Blood? ❖ Venipuncture
617 619 619
Equipment and Supplies
❖ Vacuum Tube System
622
Multisample Needles Holders and Adapters Vacuum Tubes
❖ Winged Infusion (Butterfly) System ❖ Blood Collection Tray ❖ Performing the Venipuncture Assembling Equipment and Supplies
626 627 628
xviii
❖
CONTENTS
Identifying the Patient Positioning the Patient Selecting the Site
❖ ❖ ❖ ❖ ❖ ❖
Specimen Collection by the Syringe Method
631
Specimen Collection by the Vacuum Tube Method
632
Specimen Collection by the Butterfly Method
632
Patient Response and Complications
632
The Failed Venipuncture
634
Criteria for Specimen Rejection
634
Improper Labeling of Specimen Tubes Use of Incorrect Specimen Tubes Incorrect Collection Time Incorrect Specimen Handling Hemolyzed and Lipemic Specimens
❖ The Capillary Puncture
636
Equipment Common Sites for Collection Preparing the Site Collecting the Specimen Order of Draw
❖ General Guidelines for Specimen Handling
638
PROCEDURE 26-1 Venipuncture (Syringe Method)
639
PROCEDURE 26-2 Venipuncture (Vacuum Tube Method)
642
PROCEDURE 26-3 Venipuncture (Butterfly Method)
645
PROCEDURE 26-4 Perform a Capillary Puncture
647
CHAP TER 2 7 Urinalysis ❖ Composition of Urine ❖ Specimen Collection
652 653 654
Urine Specimen Containers Methods of Collection
❖ Quality Control ❖ Routine Urinalysis ❖ Physical Examination
658 659 659
Color Clarity/Turbidity Specific Gravity
❖ Chemical Examination
662
Quality Control for Reagent Test Strips Reagent Strip Analyzers
❖ Confirmatory Tests
664
Clinitest Ictotest Acetest Sulfosalicylic Acid (SSA) Test
❖ Microscopic Examination
665
PROCEDURE 27-1 Instruct a Patient on a Clean-Catch Midstream Urine Collection
673
CONTENTS
PROCEDURE 27-2 Perform a Physical and Chemical Urinalysis and Prepare a Microscopic Slide for the Provider
CHAP TER 2 8 Hematology and Coagulation Studies ❖ Hemopoeisis ❖ Blood Components
❖
xix
674
679 680 681
Plasma Erythrocytes Leukocytes Thrombocytes
❖ Basic Hematology Studies ❖ The Complete Blood Count (CBC)
682 683
Red Blood Cell Count White Blood Cell Count Platelet Count Hemoglobin Hematocrit Differential Count Red Blood Cell Indices
❖ Erythrocyte Sedimentation Rate (ESR) ❖ Automated Hematology Analyzers ❖ Coagulation Tests
692
PROCEDURE 28-1 Perform a Microhematocrit
695
PROCEDURE 28-2 Prepare a Differential Blood Smear
696
PROCEDURE 28-3 Perform an Erythrocyte Sedimentation Rate
698
CHAP TER 2 9 Microbiology ❖ ❖ ❖ ❖
693 694
701
Classification of Microorganisms
702
Divisions of Microbiology
703
Binomial Nomenclature System for Bacteria
703
Characteristics of Bacteria
703
Basic Bacterial Cell Structure Morphology of Bacteria Classification by Staining Reaction
❖ Specimen Collection and Safe Handling Requirements
706
General Specimen Collection Guidelines Specific Specimen Collection Requirements
❖ Identification of Bacteria
709
The Culture Growth Media Direct and Biochemical Tests Streptococcus Identification Rapid Strep Tests
❖ Sensitivity Testing ❖ Special Microscopic Techniques The Wet Mount Hanging Drop Method
713 714
xx
❖
CONTENTS
❖ Virology
717
Identification of Viruses
❖ Parasitology
717
Identification of Parasites
❖ Mycology
720
Identification of Fungi
❖ Quality Control
721
PROCEDURE 29-1 Prepare a Urine Specimen for Culture and Sensitivity Using a Urine Transport System
723
PROCEDURE 29-2 Collect a Throat Specimen and Perform a Rapid Strep Test 725 PROCEDURE 29-3 Collect a Wound Specimen
726
PROCEDURE 29-4 Prepare a Wet Mount or Hanging Drop Slide
727
PROCEDURE 29-5 Instruct a Patient on Fecal Specimen Collection for Ova and Parasite Testing
728
CHAP TER 3 0 Clinical Chemistry and CLIA Waived Rapid Tests 732 ❖ Clinical Chemistry Tests
734
Quality Control
❖ Specimen Requirements
734
Serum Plasma Whole Blood
❖ Appearance of Serum and Plasma ❖ Profiles and Panels
736 736
Hepatic/Liver Profile Renal Profile Lipid Profile Cardiac Profile Thyroid Panel
❖ Glucose Testing
740
Fasting Blood Glucose Level Two-Hour Postprandial Blood Glucose Level Glucose Tolerance Test (GTT) Glycosylated Hemoglobin (HbA1c)
❖ Additional Chemistry Tests ❖ Serology/Immunology Tests
743 744
Rapid Tests Common Serology Tests
❖ Blood Typing
747
ABO Blood Typing Rh Blood Typing
❖ Drug Testing
748
Chain of Custody
PROCEDURE 30-1 Measure Blood Glucose Using a Handheld Monitor
753
PROCEDURE 30-2 Perform a Urine Pregnancy Test
754
PROCEDURE 30-3 Perform a CLIA Waived Mono Test
756
CONTENTS
CHAP TER 3 1 Diagnostic Imaging ❖ Radiology Overview ❖ Legal Considerations for Taking X-Rays ❖ X-Ray Equipment
❖
xxi
759 760 761 761
Digital Radiography
❖ The Medical Assistant’s Role in Radiographic Procedures
762
Positioning the Patient
❖ ❖ ❖ ❖
Common Types of X-Rays Performed in the Office
763
Processing and Displaying X-Ray Films
763
Storing and Disposing of X-Ray Films
765
Safety Precautions
765
Personnel Safety Precautions Patient Safety Precautions
❖ Scheduling Radiological Procedures Outside the Office
767
Patient Preparation Instructions Explaining the Procedure
❖ Radiological Procedures Commonly Performed Outside the Office ❖ Other Diagnostic Imaging Procedures
769 771
Computed Tomography (CT) Scan Magnetic Resonance Imaging (MRI) Ultrasound/Sonography
❖ Nuclear Medicine ❖ Radiation Therapy
CHAP TER 3 2 Fundamentals of Pharmacology ❖ Drug Origins
773 774
778 780
Drug Sources
❖ Medicinal Uses of Drugs ❖ Drug Classifications ❖ Pharmacodynamics
781 782 786
Dose Response Drug Actions
❖ Pharmacokinetics
789
Drug Effects Factors that Affect Drug Actions
❖ Drug Names ❖ Medication Tasks ❖ Regulations and Legal Classifications of Drugs
789 791 791
Controlled Substances
❖ The Medication Order/Prescription Writing
795
Prescription Abbreviations Rules for Writing or Calling in Prescriptions for Controlled Substances Tamper-Resistant Prescription Pads
❖ Drug Resources The Physician’s Desk Reference U.S. Pharmacopecia/National Formulary
798
xxii
❖
CONTENTS
Drug Product Package Inserts Drug Resources on the Internet
❖ Safe Drug Administration
798
Seven Rights of Drug Administration Safety and Continuity during Medication Administration
❖ Routes of Medication Administration
801
Enteral Routes Parenteral Medications
PROCEDURE 32-1 Maintain Medication and Immunization Records
807
PROCEDURE 32-2 Write a Prescription
808
PROCEDURE 32-3 Administer an Oral Medication
810
PROCEDURE 32-4 Administer a Topical Medication
811
PROCEDURE 32-5 Administer a Transdermal Medication
813
PROCEDURE 32-6 Administer a Rectal Suppository
815
CHAP TER 3 3 Dosage Calculations ❖ Medication Order ❖ Medication Math Fundamentals
820 821 821
The Apothecary System The Metric System Household Measurements
❖ Calculating Drug Dosages for Administration
827
Rounding Equations Proportional Method Formula Method Calculating Pediatric Dosages
❖ Calculating Insulin Dosages
830
Types of Insulin
❖ Reading Medication Labels
830
Warning Labels
CHAP TER 3 4 Administration of Parenteral Medications ❖ Administration of Parenteral Medications
835 837
Parenteral Equipment and Supplies Preparing Medications General Guidelines for Parenteral Medications
❖ Routes of Administration
848
Intradermal Injections Subcutaneous Injections Intramuscular Injections
❖ Parenteral Complications ❖ Immunizations
856 856
Contraindications and Precautions in Vaccine Administrations
❖ Basics of Intravenous Therapy Equipment and Supplies Employed in Intravenous Therapy Documentation of IV Therapy Risks, Complications, and Adverse Reactions of IV Therapy Discontinuation of Intravenous Infusion Therapy
858
❖
CONTENTS
xxiii
❖ Intra-Articular Injections
864
PROCEDURE 34-1 Withdraw Medication from a Vial
864
PROCEDURE 34-2 Withdraw Medication from an Ampule
866
PROCEDURE 34-3 Reconstitute a Powdered-Base Medication with a Diluent
868
PROCEDURE 34-4 Mix Two Medications into One Syringe
870
PROCEDURE 34-5 Load a Cartridge or Injector Device
872
PROCEDURE 34-6 Administer an Intradermal Injection
874
PROCEDURE 34-7 Administer a Subcutaneous Injection
876
PROCEDURE 34-8 Administer an Intramuscular Injection
878
PROCEDURE 34-9 Administer a Z-Track Medication
879
CHAP TER 3 5 Urgent Care and Emergency Procedures ❖ On the Scene Emergency Procedures
883 884
Responsibilities of a First Responder
❖ The Urgent Care Industry
889
Departments within an Urgent Care Center
❖ Preparing Personnel for Emergencies ❖ Triaging in Ambulatory Care
893 893
Life-Threatening Conditions Anaphylaxis Bleeding Emergencies Non-Life-Threatening Emergencies
PROCEDURE 35-1 Apply First Responder Principles during an Emergency to an Adult
915
PROCEDURE 35-2 Control Bleeding in the Medical Office
917
PROCEDURE 35-3 Splint an Arm
919
PROCEDURE 35-4 Treat the Patient for Shock
920
Appendix A Medical Abbreviations Appendix B ISMP’s List of Error-Prone Abbreviations, Symbols, and Dose Designations Appendix C Commonly Misspelled Everyday Terms Appendix D Commonly Misspelled Medical Terms Appendix E Top 50 Drugs Glossary Index
923 927 931 933 934 936 953
l i s t of Pr o c e d u r e s PROCEDURE 2-1
Performing Routine Maintenance on Clinical Equipment
PROCEDURE 3-1 Create and Maintain the EMR Using SynapseEHR 1.0 Software
33 58
PROCEDURE 5-1 Conducting a Patient Interview and Completing a Patient History Form
102
PROCEDURE 6-1 Conduct and Record Results from an In-Office Screening
120
PROCEDURE 6-2
122
Conduct a Follow-Up Interview and Develop a Progress Note
PROCEDURE 7-1 Perform a Telephone Screening
143
PROCEDURE 7-2
Screen and Follow Up on Test Results (Determine the Order of Prioritization)
144
PROCEDURE 8-1
Effectively Communicate with Patients from Different Cultures
169
PROCEDURE 8-2 Effectively Communicate with Sight Impaired or Blind Patients
170
PROCEDURE 8-3 PROCEDURE 8-4 PROCEDURE 9-1
Effectively Communicate with Hearing Impaired or Deaf Patients When an Interpreter Is Present
172
Effectively Communicate with a Hearing Impaired or Deaf Patient Who Speech Reads
173
Provide Instruction for Health Maintenance and Disease Prevention and Identify Community Resources That Will Assist the Patient
184
PROCEDURE 10-1 Perform Medically Aseptic Handwashing
216
PROCEDURE 10-2 Perform an Alcohol-Based Hand Rub
217
PROCEDURE 10-3 Remove Contaminated Gloves
218
PROCEDURE 11-1 Obtain the Height and Weight of an Adult Patient
242
PROCEDURE 11-2 Obtain an Oral Body Temperature
244
PROCEDURE 11-3 Obtain an Aural Body Temperature
245
PROCEDURE 11-4 Obtain an Axillary Body Temperature
247
PROCEDURE 11-5 Obtain a Temporal Artery Body Temperature
248
PROCEDURE 11-6 Obtain a Radial Pulse Rate and Respiration Rate
249
PROCEDURE 11-7 Obtain an Apical Pulse Rate
251
PROCEDURE 11-8 Obtain a Blood Pressure Measurement Using the Palpatory Method
252
PROCEDURE 12-1 Prepare the Examination Room
270
PROCEDURE 12-2 Position and Drape the Patient
271
L I S T O F P RC OO CN ED TE UN RT ES
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xxv
PROCEDURE 12-3 Assist with the General Physical Examination
273
PROCEDURE 13-1 Snellen Chart Visual Acuity Testing
291
PROCEDURE 13-2 Screen Near Visual Acuity
292
PROCEDURE 13-3 Ishihara Test for Color Vision
293
PROCEDURE 13-4 Eye Instillation
294
PROCEDURE 13-5 Eye Irrigation
295
PROCEDURE 13-6 Ear Instillation
297
PROCEDURE 13-7 Ear Irrigation
298
PROCEDURE 14-1 Perform a Fecal Occult Blood Test
313
PROCEDURE 14-2 Instruct the Patient on How to Collect a Fecal Specimen
315
PROCEDURE 14-3 Assist with a Flexible Sigmoidoscopy
316
PROCEDURE 15-1 Perform a Standard 12-Lead Electrocardiogram with a Multichannel Unit
342
PROCEDURE 15-2 Apply the Holter Monitor
344
PROCEDURE 16-1 Perform a Spirometry Test
364
PROCEDURE 16-2 Perform Pulse Oximetry
365
PROCEDURE 16-3 Obtain a Sputum Specimen and Prepare a Smear
366
PROCEDURE 16-4 Administer a Nebulizer Treatment
368
PROCEDURE 17-1 Assist with a GYN Exam and Pap Test
399
PROCEDURE 17-2 Instruct the Patient in Breast Self-Examination
401
PROCEDURE 17-3 Assist with the Prenatal Exam
402
PROCEDURE 18-1 Urinary Catheterization
422
PROCEDURE 19-1 Obtain the Height/Length and Weight of an Infant
446
PROCEDURE 19-2 Obtain the Temperature of an Infant or Young Child
447
PROCEDURE 19-3 Perform a PKU on a Newborn
449
PROCEDURE 19-4 Perform a Pediatric Injection
451
PROCEDURE 21-1 Administer Heat Therapy Treatments
494
PROCEDURE 21-2 Administer Cold Therapy Treatments
496
PROCEDURE 21-3 Instruct a Patient to Use a Cane
498
PROCEDURE 21-4 Instruct a Patient to Use Axillary Crutches
499
PROCEDURE 21-5 Instruct a Patient to Use a Walker
500
PROCEDURE 21-6 Assist a Patient from the Wheelchair to the Exam Table and Back to the Wheelchair 501 PROCEDURE 22-1 Sanitization and Lubrication of Instruments
518
PROCEDURE 22-2 Chemical Disinfection of Instruments
519
PROCEDURE 22-3 Wrap Items for Sterilization and Operate an Automated Autoclave
521
PROCEDURE 23-1 Apply Skin Closures
546
PROCEDURE 23-2 Suture or Staple Removal
548
PROCEDURE 24-1 Perform a Surgical Handwash and Apply Surgical Gloves
570
PROCEDURE 24-2 Prepare the Patient’s Skin for the Surgical Procedure Using a One-Step Scrub
573
PROCEDURE 24-3 Disinfect a Surgical Tray and Place a Sterile Barrier on the Tray
574
PROCEDURE 24-4 Open Sterile Items and Place Them on the Sterile Field
576
PROCEDURE 24-5 Set Up a Complete Sterile Tray and Pour a Sterile Solution
578
PROCEDURE 24-6 Apply Surgical Attire
581
PROCEDURE 24-7 Remove an Old Dressing, Irrigate the Wound, and Apply a New Dressing
584
PROCEDURE 25-1 Review and Report Laboratory Results
611
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❖
CIOS N L T TOE FN T PS ROCEDURES
PROCEDURE 25-2 Specimen Collection for Offsite Testing
611
PROCEDURE 25-3 Use the Microscope
613
PROCEDURE 26-1 Venipuncture (Syringe Method)
639
PROCEDURE 26-2 Venipuncture (Vacuum Tube Method)
642
PROCEDURE 26-3 Venipuncture (Butterfly Method)
645
PROCEDURE 26-4 Perform a Capillary Puncture
647
PROCEDURE 27-1 Instruct a Patient on a Clean-Catch Midstream Urine Collection
673
PROCEDURE 27-2 Perform a Physical and Chemical Urinalysis and Prepare a Microscopic Slide for the Provider
674
PROCEDURE 28-1 Perform a Microhematocrit
695
PROCEDURE 28-2 Prepare a Differential Blood Smear
696
PROCEDURE 28-3 Perform an Erythrocyte Sedimentation Rate
698
PROCEDURE 29-1 Prepare a Urine Specimen for Culture and Sensitivity Using a Urine Transport System
723
PROCEDURE 29-2 Collect a Throat Specimen and Perform a Rapid Strep Test
725
PROCEDURE 29-3 Collect a Wound Specimen
726
PROCEDURE 29-4 Prepare a Wet Mount or Hanging Drop Slide
727
PROCEDURE 29-5 Instruct a Patient on Fecal Specimen Collection for Ova and Parasite Testing
728
PROCEDURE 30-1 Measure Blood Glucose Using a Handheld Monitor
753
PROCEDURE 30-2 Perform a Urine Pregnancy Test
754
PROCEDURE 30-3 Perform a CLIA Waived Mono Test
756
PROCEDURE 32-1 Maintain Medication and Immunization Records
807
PROCEDURE 32-2 Write a Prescription
808
PROCEDURE 32-3 Administer an Oral Medication
810
PROCEDURE 32-4 Administer a Topical Medication
811
PROCEDURE 32-5 Administer a Transdermal Medication
813
PROCEDURE 32-6 Administer a Rectal Suppository
815
PROCEDURE 34-1 Withdraw Medication from a Vial
864
PROCEDURE 34-2 Withdraw Medication from an Ampule
866
PROCEDURE 34-3 Reconstitute a Powdered-Base Medication with a Diluent
868
PROCEDURE 34-4 Mix Two Medications into One Syringe
870
PROCEDURE 34-5 Load a Cartridge or Injector Device
872
PROCEDURE 34-6 Administer an Intradermal Injection
874
PROCEDURE 34-7 Administer a Subcutaneous Injection
876
PROCEDURE 34-8 Administer an Intramuscular Injection
878
PROCEDURE 34-9 Administer a Z-Track Medication
879
PROCEDURE 35-1 Apply First Responder Principles during an Emergency to an Adult
915
PROCEDURE 35-2 Control Bleeding in the Medical Office
917
PROCEDURE 35-3 Splint an Arm
919
PROCEDURE 35-4 Treat the Patient for Shock
920
p r e f a c e Welcome to Clinical Medical Assisting: A Professional, Field Smart Approach to the Workplace! The field of medical assisting is continually evolving. Today’s medical assistant is being called upon to perform more complex tasks and to accept greater loads of responsibility than ever before. This is especially true in the clinical arena. With the shortage of nurses and the influx of medical assistants, ambulatory health care centers are relying on medical assistants working in a clinical capacity to possess strong technical skills, patient screening skills, and wonderful communication skills. Medical assistants must understand that being a good clinician (which is used in this context to refer to a medical professional who works in a clinical capacity) requires more than just being technically proficient—it requires the medical assistant to think on a higher level and to have superb problem solving skills. Today’s office supervisors are looking for individuals who possess strong professional skills and can take theoretical concepts learned in the classroom and apply them to the workplace. Because we are now living in the age of paperless records, medical assistants must also have a good grasp of the latest electronic medical record (EMR) functionalities and have a clear understanding of how privacy laws affect health care members working on the clinical team. This book is designed to empower medical assisting students with the knowledge that is necessary to meet and exceed the expectations of today’s health care facilities. This book will help to prepare medical assisting students for the next generation of health care by providing them with educational resources that will not only be valuable in the health care market today, but for many years to come.
Motivation for the Content that Appears in the Book The core material for the book incorporates theoretical and technical information from the clinical standards set forth by CAAHEP and ABHES. The remainder of
the book’s content is the result of feedback received from educators and office supervisors across the country regarding both the latest trends in ambulatory medicine and common deficiencies among today’s medical assistants. Common areas of concern among supervisors and educators include a lack of professional or “soft” skills and weak documentation and screening skills among today’s medical assistants. As a result of their important feedback, individual chapters have been designed to specifically address these areas of concern. One of the latest trends in today’s ambulatory health centers is the implementation of EMR technology. This book introduces and reinforces the use of EMR by presenting special tool boxes in each chapter that explain how different clinical responsibilities are made easier with the implementation of EMR.
Organization of the Book The content that appears in the book is written in a contemporary format and incorporates many tables and tool boxes that help to organize and simplify information. Each chapter integrates important clinical and general content designed to correlate with institutions that are CAAHEP or ABHES accredited. Chapters are grouped according to subject matter: Chapters 1–2, Building a Solid Foundation These chapters focus on the importance of professionalism and credentialing for today’s medical assistant, especially those working in a clinical capacity. These chapters help students understand the importance of a professional mindset when working as a clinical medical assistant. Chapter 1 lists and describes specialty credentialing that is available for medical assistants working in a clinical capacity, so that the student can set goals early in the educational process. Chapter 2 concerns organizational and time management skills, and assists students in learning how to organize themselves both during the educational process and upon entering the industry.
xxviii
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PREFACE
Chapters 3–4, The Medical Record and the Importance of Documentation These chapters focus on the importance of medical records and teach the student how charts are organized. These chapters also discuss laws that affect medical records and provide tips on how to apply legal principles when using information contained within a chart. Chapter 3 includes an entire section on EMR technology and teaches students about the application of the latest functionalities available from software vendors. Chapter 4 is devoted to medical documentation. Common abbreviations used in ambulatory medicine, step-by-step instructions for every type of documentation that medical assistants perform, and numerous documentation samples are included. Chapters 5–9, Communicating on a Clinical Level Today, medical assistants working in ambulatory medicine have more responsibility in conducting patient screenings. These chapters concern developing the patient history and conducting in-office and telephone screenings. Many medical assistants have a difficult time screening patients with special needs, such as hearing-impaired patients, blind patients, and patients from other cultures. Chapter 8 teaches how to work with patients with special needs and from various cultures. Chapter 9 focuses on patient education, and includes techniques that can be used when setting up educational sessions. Chapters 10–21, Assisting with Examinations and Procedures These chapters include information that is essential to know when assisting with various types of examinations and procedures. The examinations and procedures that are covered apply to both general practice offices and various specialty practices. Topics include infection control, vital signs, positioning and draping procedures, and a host of specialty procedures. Chapters 22–24, Asepsis and Assisting with Sterile Procedures These chapters cover essential infection control components that are necessary when performing medical and surgical procedures. Instrument identification, instrument maintenance techniques, and sterilization principles are included, as well as the latest information on proper wound care and bandaging techniques. Chapters 25–30, Medical Laboratory Concepts These chapters focus on the various types of testing that are performed in the physician’s office laboratory. Also covered are moderately and highly complex tests that are commonly performed in hospital and reference
laboratories. Students will learn how to perform all of the major tests that are performed in waived labs, as well as phlebotomy. Specialty chapters include hematology, urinalysis, clinical chemistry, and microbiology. These chapters incorporate many tables to help simplify information. Chapter 31, Diagnostic Radiology and Ultrasound This chapter focuses on the many diagnostic and radiological exams that are performed in hospitals and other diagnostic centers. Students will learn the purpose of such testing and common prep for each procedure. Chapters 32–34, Pharmacology These chapters focus on the uses of drugs and how the body metabolizes medications. Dosage calculation formulas, drug classifications, prescription writing, and procedures for administering medications are all covered in these chapters. Chapter 35, Emergency Care This chapter covers common emergencies that occur both in the office and on the street. The student will learn how to respond to emergencies and be refreshed on CPR techniques. Because urgent care is one of the fastest growing health care industries, special emphasis has been placed on working in an urgent care environment.
Chapter Organization Each chapter includes the following components: ❖ Essential Terms are bolded terms that are essential for comprehending the material contained within the chapter. ❖ The Chapter Outline delineates how the material is organized within each chapter. ❖ Developmental Objectives are objectives to focus on when reading each chapter. ❖ Key Competencies provide a direct link to the procedures and professional skills taught within each chapter, with correlations to ABHES and CAAHEP standards. ❖ Illustrated Procedures give step-by-step instructions that correlate with the chapter contents. Procedures list the rationales for important steps and many procedures incorporate pictures or illustrations for easy referencing. ❖ The Chapter Summary provides final thoughts to consider after reading the chapter. ❖ Field Application Challenges are hypothetical situations related to the chapter material. First, a scenario is presented, followed by corresponding questions to think about and answer.
PREFACE
❖ The Chapter Assessment consists of a list of questions that correspond to the material covered in the chapter. ❖ Web Activities provide opportunities to further explore and research information related to the content that appears in the chapter. ❖ The StudyWare Connection and DVD Link apply a multimedia approach to learning the chapter content, directing the reader to interactive activities and assessment on the StudyWare Software CD-ROMs.
Tool Boxes This book is loaded with tool boxes that help to simplify and reinforce chapter content. Tool boxes have a variety of themes and help to break up heavy text. Tool box usage is based on material that is presented in each chapter; therefore, not all tool boxes are used in every chapter. ❖ Field Smarts: This tool box provides quick facts relevant to book content. Informative facts, time saving tips, and organizational tips are examples of information found in these boxes. ❖ Site Check: This tool box helps readers understand that each office is accountable to outside agencies in regards to medical records, documentation, keeping logs, and implementing patient safety standards. ❖ Patient Tutor: This tool box provides excellent data and tips that can be used during patient educational sessions. ❖ Patient Perspective: This tool box is designed to stimulate readers to think about how patients feel when put in certain situations. They reinforce the importance of compassion and empathy. ❖ EMR Application: This tool box educates on various functionalities of EMR that can be utilized to help organize and expedite many of the clinical tasks that medical assistants perform. ❖ HIPAA Patrol: This tool box provides important guidelines that must be followed when working with protected health information.
❖
xxix
Ancillary Products Supplemental material supporting this book includes the following: ❖ StudyWare Software CD-ROMs: Included free with this book, the CD-ROMs contain: StudyWARE games, quizzes, animations, and video clips correlating to the DVD Link; the Competency Challenge; the Critical Thinking Challenge; and an audio library. ❖ Workbook: The Workbook is a robust learning tool that provides numerous learning opportunities for students through Vocabulary and Acronym Reviews, Skill Application exercises, additional Field Application Challenges, and hands-on activities that utilize EMR software. Competency Checklists that include mapping to ABHES and CAAHEP competency numbering are provided for each procedure. ❖ SynapseEHR: An Electronic Charting Simulation: This is a generic EMR software program that is included free with the Workbook on CD-ROM. Support documentation for SynapseEHR is provided on the Online Companion that accompanies this book. ❖ Instructor’s Manual: The Instructor’s Manual includes Chapter Lesson Plans, assignments, competency mapping, and answer keys to the book and Workbook. ❖ Instructor’s Resources: The Instructor’s Resources CD-ROM offers several tools, including a Computerized Test Bank, PowerPoint presentations, an Image Library, and electronic Instructor’s Manual files to help build complete lesson plans that include handouts, presentations, computergenerated tests, and more. ❖ Online Companion: The Online Companion Web site can be accessed at www.delmar.cengage .com/companions. Choose “Allied Health” on the left navigational bar and then click on the title of this book. It contains materials for both instructors and students, including SynapseEHR support materials, customizable competency checklists, detailed chapter outlines, additional chapter material and updates, correlation guides, and more.
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PREFACE
About the authors Michelle E. Heller, CMA (AAMA), RMA
Lynette M. Veach, MLT (ASCP)
Michelle Heller is an honors graduate from Columbus Para-Professional in Columbus, Ohio. Michelle has been a medical assistant for the past 30 years and has worked in a variety of professional medical office settings, including as an office manager for a six-clinician practice. Michelle currently serves both as the Director of Education and the Medical Assisting Program Director for Ohio Institute of Health Careers. She has received a variety of “Outstanding Teacher” awards from institutions in which she has taught and from the Ohio Council of Private Career Schools and Colleges. Michelle has worked on an array of publishing projects, including Delmar’s Clinical Handbook for the Medical Office, and has served as a subject matter expert for a variety of ancillary products. She is also a frequent presenter at the local, state, and national levels on a variety of health and education topics. Michelle is a chronic researcher and has spent countless hours in the last six years researching information for this book in order to have the most current and accurate information possible.
Lyn Veach is an honors graduate from Career Academy where she received a certificate in medical assisting. She later received her AAS in Medical Laboratory Technology from Columbus Technical Institute— now Columbus State Community College—where she was recognized as the class valedictorian and graduated summa cum laude. Lyn has worked in a variety of settings throughout the last 30 years including physician offices, reference laboratories, and hospital laboratories. She has taught both medical assisting and physician’s office laboratory courses at Aristotle Institute of Technology and Columbus State Community College. Lyn has contributed chapters and written ancillary materials for a variety of publishing projects.
PREFACE
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ACKNOWLEDGMENTS The amount of time invested into a project such as this requires huge sacrifices not only from members of the author team but from their family members and friends as well. I want to thank my family and friends for their prayers, patience, and support throughout this entire project. I would like to thank my coauthor Lyn Veach and all the contributors and reviewers who spent countless hours writing, reviewing, and providing input to help mold this project into the final product. I want to thank Rhonda Dearborn, Senior Acquisitions Editor at Delmar Cengage Learning for tapping me for this project and for her support throughout the past several years. I want to especially recognize Sarah Prime, Product Manager and “coach,” for her encouragement, support, and guidance throughout this project. Two people that worked very hard to take this from a manuscript to a beautiful book are Stacey Lamodi, Senior Content Project Manager at Delmar Cengage Learning, and Nicole Lee Petel at Lachina Publishing Services— thank you both for your hard work and attention to detail. A special thanks to Jack Pendleton, Senior Art Director, for his creative eye in developing the page layout, devising the color schemes in the book, and overseeing the photo shoot. Exceptional thanks to Tom Stock, Stock Studios Photography, for his superb photography and for even stepping in as a model. There are many others at Delmar and Lachina Publishing who worked on the book, including members of the editorial and marketing teams—thank you all for your input and hard work. I can’t end this acknowledgement without thanking my school director Angelique Walker and former school director Goldean Gibbs, as well as teaching colleagues for their support and willingness to work through scheduling changes to accommodate my deadlines. Students—you are my passion and inspiration for writing this book—remember to “Learn for life, not just for the test,” and to always put your patients above yourself. Michelle E. Heller
I gratefully acknowledge and thank my children Christopher and Kelly, to whom this book is also dedicated, for their love, support, encouragement, understanding, and patience during this monumental endeavor, and for never giving up on me even when I was ready to give up on myself. I wish to thank God and my coauthor Michelle Heller for believing in my abilities and giving me this wonderful opportunity. I also thank Sarah Prime, Product Manager, for her steadfast and valuable guidance. Lynette M. Veach
Contributors The authors and publisher would like to acknowledge the following educators and professionals for contributing to the content of this book: Toni Hallgren, RN Contributing material to Chapters 10–21 Sheri Greimes, CMA (AAMA) Contributing material to Chapters 10–21 and Chapters 32–34 Jacqueline Marshall, M.Ed. Contributing material to Chapters 32–34 Melinda Parker, CMA (AAMA) Contributing material to Workbook assignment sheets and competencies for Chapters 1–9, 14, 16, 18, 22–24, 32–35 The authors and publisher would also like to acknowledge the following facilities and professionals for helping facilitate and execute the photo shoot which provided so many new photos for this book: America’s Urgent Care Upper Arlington, OH With special thanks to Dr. Karl Valentine, President, and Olivia Vance, Director of Operations.
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ACKNOWLEDGMENTS
Ohio Institute of Health and Careers Columbus, OH With special thanks to Roseanna Catella, Angelique Walker, and the staff and students.
Mary Ellen Brown, CMA (AAMA), PBT (ASCP) Instructor Stone Academy Hamden, CT
Ohio Orthopedic Surgery Institute Columbus, OH With special thanks to Pam Brown.
Nia J. Bullock BS, Ph.D. Dean of Academics, Medical Instructor Miller-Motte Technical College Cary, NC
Stock Studios Photography Saratoga Springs, NY With special thanks to Tom Stock.
Reviewers The following educators provided feedback and thoughtful comments throughout the development process, which helped shape the final product. A special thank you to Pat Gallagher Moeck for doing a thorough technical review on the final chapters and providing critical feedback.
George Fakhoury, MD, DORCP, CMA (AAMA) Academic Program Manager, Health Care Heald College San Francisco, CA Jane Garrett, MA Medical Assisting Program Manager Ohio Institute of Health Careers Columbus, OH Marsha Holtsberry, CMA (AAMA), CPC-A Medical Administrative Specialist Program Manager Ohio Institute of Health Careers Columbus, OH
Julie Akason, RN, BSN, PHN, M.Ed. Program Chair of Medical Assisting Argosy University—Twin Cities Eagan, MN
Rebecca Gibson Lee, MTE, CMA (AAMA), ASPT Professor/Program Director, Medical Assisting The University of Akron Akron, OH
Diana Alagna, RN, CPT, AHI Branford Hall Career Institute Southington, Connecticut
Cynthia Y. Lilly, RMA Lead Instructor, Allied Health Programs Career Academy Anchorage, AK
Tricia Berry, MATL, OTR/L Director of Clinical Placement School of Health Sciences Kaplan University Carole Berube, MA, MSN, BSN, RN Professor Emerita in Nursing Instructor in Medical Assisting Bristol Community College Fall River, MA
Wilsetta McClain, NCPT, RMA, MBA Department Chair Baker College of Auburn Hills Auburn Hills, MI Kerri Jones AAS, CMA (AAMA) Medical Assisting P.M. Manager Ohio Institute of Health Careers Columbus, OH
Kay E. Biggs, BS, CMA (AAMA) Coordinator/Advisor, Medical Assisting Technology Columbus State Community College Columbus, OH
Pat Gallagher Moeck, PhD, MBA, CMA (AAMA) Director, Medical Assisting Program El Centro College Dallas, TX
Cindi Brassington, MS, CMA (AAMA) Associate Professor of Allied Health Quinnebaug Community College Danielson, CT
Sherry L. Mulhollen, CMA (AAMA), BS Allied Health Program Director Elmira Business Institute Elmira, NY
ACKNOWLEDGMENTS
Diana Reeder, CMA (AAMA), AAS Program Coordinator/Director Maysville Community & Technical College—Rowan Campus Morehead, KY Amir Sajadian, BS, MA Medical Assisting Instructor El Paso Community College El Paso, TX Lee Speck, MT Ohio State University Hospital Columbus, OH
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Fauna Stout, BS, CMA (AAMA) Coordinator/Advisor, Medical Assisting Technology Columbus State Community College Columbus, OH Danielle Schortzmann Wilkin, MS, MT (ASCP) Chair of the Allied Health Dept Goodwin College East Hartford, CT Ann M. Zeller, CMA (AAMA), AAS Medical Assisting Instructor Ohio Institute of Health Careers Columbus, OH
How to Use This Book Tool Boxes Tool boxes help to simplify and reinforce chapter content, and bring a real-world perspective to the material presented. Field Smarts provides quick facts, time-saving hints, and organizational tips. Critical Thinking Challenges are quick checkpoints that apply the chapter content to real-world scenarios. EMR Application provides a link to the functionalities and capabilities of EMR software to help organize and expedite many of the clinical tasks medical assistants perform. HIPAA Patrol gives important guidelines for working with protected health information. Patient Tutor provides excellent data and tips that can be used during patient education sessions. Patient Perspective reinforces the importance of compassion and empathy by presenting the patient’s point of view. Site Check helps reinforce that offices are accountable to outside agencies in regards to medical records, documentation, keeping logs, and implementing patient safety standards.
Key Competencies Key Competencies provide a direct link to the procedures and professional skills that are taught within the chapter, and their correlation to ABHES and CAAHEP competencies.
Field Application Challenges Field Application Challenges present real-life scenarios and ask the student to respond to a series of correlating questions.
StudyWare Challenge StudyWare Challenges apply a multimedia approach to learning the chapter content, directing the learner to complete certain interactive activities and assessments.
DVD Link Some chapters also include a DVD link, which indicate that the software contains video case study scenarios for that chapter.
Procedures Illustrated Procedures give step-by-step instructions and rationales, and incorporate documentation samples, photos, and illustrations for easy referencing.
How to Use The Studyware Software CD-ROMs The StudyWARE Software CD-ROMs are included in the back of this book to bring a multimedia approach to learning.
StudyWARE StudyWARE includes video clips that relate to the DVD Link, interactive activities, and assessment quizzes for each chapter. Activities include crossword puzzles, flash cards, concentration, spelling bee, and a championship game.
Animations Library Twenty anatomy and physiology animations with audio are included within the StudyWare program that support and reinforce chapter content.
The Competency Challenge Simulating a virtual externship, this program includes video-based case studies and interactive exercises that provide practice with the clinical competencies for the medical assistant.
The Critical Thinking Challenge The Critical Thinking Challenge game simulates a three-month externship in a medical office, where the user must exercise critical thinking skills to choose the most appropriate response to the series of scenarios presented. If the user succeeds in making good decisions, the user will be offered a job with the medical office or receive a letter of recommendation, and can print out a certification of completion.
Medical Terminology Audio Library Practice pronunciation and recognition of medical terms with the Medical Terminology Audio Library. Search for terms either by word or body system, and listen to the correct pronunciation while reading the spelling and definition on screen.
S u ppl e m e n t s at-a - gl a n c e SUPPLEMENT
WHAT IT IS
WHAT’S IN IT
StudyWARE Software CD-ROMs
2 CD-ROMs in the back of the book
• • • •
The Competency Challenge
Software Program (on StudyWare Software CD-ROMs)
• Video-based case studies and interactive exercises • Printable quiz scores • Printable Competency Checklist
The Critical Thinking Challenge
Software Program (on StudyWare Software CD-ROMs)
• Series of eight scenarios that challenge the user to make critical thinking decisions • Scoring, outcomes, and feedback for each decision selected • Printable Certification of Completion at the end of the program
Workbook
Print with CD-ROM
• Competency Checklists • Documentation practice and hands-on form activities • Activities corresponding to each chapter
SynapseEHR: An Electronic Charting Simulation
CD-ROM in the back of the Workbook
• • • •
Instructor’s Manual
Print
• Answer keys to the book and Workbook • Chapter Lesson Plans • Student assignments
Instructor’s Resources
CD-ROM
• • • •
PowerPoint presentations Computerized Test Bank Image Library Electronic Instructor’s Manual files
Online Companion
Web site
• • • • •
www.delmar.cengage.com/companions Click on “Allied Health,” then the title of this book Customizable Competency Checklists Detailed chapter outlines Additional chapter material and updates
StudyWARE games, video clips, quizzes The Competency Challenge The Critical Thinking Challenge Animations library of anatomy and pathology images with audio • Audio library of medical terms
Generic electronic charting software program Four modules of step-by-step activities Critical thinking questions at the end of each module Support documentation provided on the Online Companion
C H A P T E R
Journey to Professionalism Chapter Outline Professionalism and the Clinical Medical Assistant A Higher Degree of Professionalism
Developing Your Professional Persona The Internal Journey The External Journey
Developmental Objectives After completing this chapter, you should be able to: 1. Correctly spell and define the essential terms. 2. Explain why a medical assistant working in a clinical capacity may be held to a higher degree of professionalism than a medical assistant who works in an administrative capacity. 3. List six character qualities that are essential in a professional medical assistant. 4. List five external actions that must be taken in order to expand technical knowledge, communicate more effectively, and demonstrate a caring attitude toward the patient. 5. List two different types of communications and describe ways that overall communication skills can be improved. 6. Explain the importance of service when working as a medical assistant.
1 Essential Terms Accrediting Bureau of Health Education Schools (ABHES) American Association of Medical Assistants (AAMA) American Medical Technologists (AMT) appearance attitude certification Certified Medical Assistant (AAMA) [CMA (AAMA)] clinician Commission on Accreditation of Allied Health Education Programs (CAAHEP) compassion confidentiality credentialing dependability education continues
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7. List four organizations that credential medical assistants. empathy initiative integrity licensing professionalism Registered Medical Assistant (RMA) registration service tact
8. List three other credentials that medical assistants may be able to obtain with some additional coursework or field experience.
Introduction Webster defines professionalism as, “the conduct, aims, or qualities that characterize or mark a professional or a professional person.” Many people can become medical assistants, but not everyone who graduates from a medical assisting program is a “professional” medical assistant. The process that will assist you in developing professional skills can be compared to that of a journey. Your journey to become a professional medical assistant will require you to pass through two separate corridors before reaching your final destination (Figure 1-1). The internal corridor features a set of doors that represent a set of character qualities that are necessary to be a professional. To obtain the keys for these doors, you must perform an internal inventory of your own character traits and make the appropriate adjustments before gaining the respect of patients and other professionals in the industry. Secondly, you will proceed down the external corridor. This corridor will feature a set of doors that represent a set of external actions that must be taken in order to gain professional knowledge, communicate more effectively, and better serve your patients. The professional journey will require you to conduct some deep soul-searching along the way and will compel you to fine-tune areas both within your mind and within your heart. The journey will stimulate you to take actions that will enhance your outward persona, resulting in positive communication with patients and colleagues. This will assist you in enhancing personal relationships as well. Becoming a professional requires you to make a conscious decision to be kinder than you sometimes are and smarter than you sometimes act and deny yourself in order to help others. It requires you to look for the good in people and situations instead of dwelling on the bad, to go to work when you don’t feel like going, and to perform duties that you don’t feel like doing. It requires you to think on a higher level and to react in all situations with poise and dignity.
Image not available due to copyright restrictions
JOURNEY TO PROFESSIONALISM
This chapter will present you with a complete set of keys that will help to unlock your professional characteristics, one door at a time.
PROFESSIONALISM AND THE CLINICAL MEDICAL ASSISTANT Health care professionals are individuals who are bound to a code of ethics. Even though each health care profession has its own set of ethical standards, many health care programs include professionalism courses within their training programs. At the time of graduation, or during a special penning ceremony, some students or graduates of health care programs recite the ethical creed for the professions in which they have trained and take a vow to implement those standards into their daily professional lives. The field of medical assisting is no different than any other health care profession. The American Association of Medical Assistants (AAMA), American Medical Technologists (AMT), and other medical assisting
FIGURE 1-2a AAMA Code of Ethics (Copyright by the American Association of Medical Assistants, Inc. Revised October 1, 1996.)
CODE OF ETHICS of the American Association of Medical Assistants The Code of Ethics of AAMA shall set forth principles of ethical and moral conduct as they relate to the medical profession and the particular practice of medical assisting. Members of AAMA dedicated to the conscientious pursuit of their profession, and thus desiring to merit the high regard of the entire medical profession and the respect of the general public which they do serve, do pledge themselves to strive always to: A. render service with full respect for the dignity of humanity; B. respect confidential information obtained through employment unless legally authorized or required by responsible performance of duty to divulge such information; C. uphold the honor and high principles of the profession and accept its disciplines; D. seek to continually improve the knowledge and skills of medical assistants for the benefit of patients and professional colleagues; E. participate in additional service activities aimed toward improving the health and well being of the community.
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TOOL BOX
FI E L D S M A R T S Read over the AAMA code of ethics and creed and determine what kinds of adjustments you will need to make in order to comply with the standards. Start implementing these standards within your daily life now so that by the time you graduate, you will have a good grasp of what it takes to be a professional medical assistant.
certifying organizations have established their own code of ethics (Figure 1-2a) and creeds (Figure 1-2b) to which medical assistants must abide.
A Higher Degree of Professionalism So you may be asking yourself: Why is a clinical text focusing on professionalism training? After all, isn’t clinical training just about learning how to perform related technical skills? The answer is no. Before you can become a good clinician (used in this context to mean someone working in a clinical capacity), you must possess a professional demeanor. Often times, patients will hold health care professionals working in a clinical capacity to a higher standard of professionalism than those working in administrative areas. There are several contributing factors that may lead to this type of thinking.
FIGURE 1-2b AAMA Creed (Copyright by the American Association of Medical Assistants, Inc. Revised October 1, 1996.)
MEDICAL ASSISTANT’S CREED The creed of the American Association of Medical Assistants reads as follows: I believe in the principles and purposes of the profession of medical assisting. I endeavor to be more effective. I aspire to render greater service. I protect the confidence entrusted to me. I am dedicated to the care and well being of all people. I am loyal to my employer. I am true to the ethics of my profession. I am strengthened by compassion, courage, and faith.
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The Visibility Factor
The Time Factor
The first factor is visibility. The clinical medical assistant is much more visible than the medical assistant working in an administrative capacity. In many instances, the patient only sees the administrative medical assistant from the waist up. The clinical medical assistant is quite often in full view of the patient, enabling the patient to see the medical assistant from head to toe and at many different angles.
The third factor is the amount of time the clinical medical assistant spends with the patient in comparison to the administrative medical assistant. The administrative medical assistant spends anywhere from seconds to a few minutes with each patient. The clinical medical assistant may spend anywhere from a few minutes to a few hours with the patient, depending on the procedures being performed. This allows more time for the patient to make observations regarding the clinical medical assistant’s attitude, appearance, and work ethic.
The Proximity Factor The second factor is the amount of distance that usually exists between the medical assistant and patient. The administrative medical assistant normally sits at a distance of a few to several feet away from the patient. The clinical medical assistant however, works much closer to the patient. On many occasions, a clinical medical assistant is face-to-face with the patient, making it easier for the patient to make observations with regard to the medical assistant’s appearance and other professional characteristics. Figure 1-3 shows the proximity of the medical assistant to the patient when assisting the patient onto an examination table.
FIGURE 1-3 Notice the close proximity of the medical assistant to the patient when assisting the patient onto the table from a wheelchair.
The Nature of the Work The fourth factor is the nature of the work being performed. The clinical medical assistant works with the patient on a physical level, which involves a certain amount of professional intimacy. The clinical medical assistant sees parts of the patient’s body that the patient himself may never see and converses with the patient about sensitive health care matters. The patient needs to fully trust that the medical assistant is not going to share private comments that are made behind closed doors or discuss specific observations made about the patient’s body. On the other hand, the administrative medical assistant usually performs tasks related to patient billing and insurance processing. Even though this information is also considered confidential, the level of sensitivity associated with both positions is very different.
Administrative Errors verses Clinical Errors Errors may also have a bearing on the patient’s expectations. An administrative error is usually easier to correct than a clinical error because it most often involves making a correction on a bill or on an insurance claim form. A clinical error, on the other hand, is not as easily corrected and could result in great harm or even death to the patient, thus causing the patient to hold the clinical medical assistant to a higher degree of scrutiny.
DEVELOPING YOUR PROFESSIONAL PERSONA Developing professional characteristics is not something that just happens overnight. The integration of traits associated with professionalism actually begins early in life and progresses throughout one’s lifetime. From the time we are very young, we are instructed to “mind our manners,” “address our elders with respect,” and “have a good work ethic.” These are all characteristics that a professional person needs to pos-
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sess. While some people are privileged enough to hear those instructions as well as to witness them first-hand through the example of parents, relatives, and other mentors, not all people are surrounded by such positive role models during childhood. If you watch a young child with younger siblings and playmates, you can recognize that the child often mimics what has been learned from parents. If the child’s parents continually lash out and belittle the child, there is a good chance that the child will repeat the same behavior with siblings and playmates (Figure 1-4). If the child’s parents are disrespectful toward other people, such as individuals in authority positions or in certain ethnic groups, the child most likely will mimic the same behavior patterns and prejudices in adulthood. On the contrary, if a child is raised in a home where family members are respectful toward one another and talk in a positive manner when referring to people from other cultures, that child will be less likely to feel prejudice toward persons from other ethnic backgrounds and will be more likely to treat all individuals with dignity and respect. Religion or faith may have an impact on professional skills. Many religious principles are similar to the ethical principles set forth by health care certifying organi-
FIGURE 1-4 Children often mimic their parents. Notice how the older child is scolding the younger child.
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zations. For those who have been active in their areas of faith, professional standards may already be more familiar and come naturally. Friends and peers can also influence your professional persona, for better or worse. If you surround yourself with individuals who are continually negative and lack motivation, there is a greater tendency to be negative yourself; however, if you surround yourself with friends and family members who are positive and have great initiative, chances are you will possess similar traits.
The Internal Journey The introduction of this chapter compared the development of professional qualities to that of a journey. Figure 1-1 featured two corridors with several doors that needed to be unlocked before reaching the end of each corridor. The first corridor represented the internal journey or the journey of one’s thinking. The internal journey may be the hardest part of the journey because it requires you to examine personal qualities that are deep within you and to perform the necessary adjustments before you will be able to walk through each of its doors, that is, before you can acquire professional character qualities. Each door has a key that represents an important character trait necessary in the development of professionalism. Figure 1-5 is an illustration of the keys that are necessary to possess in order to complete this part of the journey.
FIGURE 1-5 This key chain represents the keys that are necessary to open the doors in the internal corridor—attitude, dependability, tactfulness, integrity, compassion, and initiative.
e
Attitud
Dependability Compassion
ss
fulne Tact
Integrity
tive
Initia
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Key #1: A Good Attitude Attitude refers to the way you feel about someone or something. Attitudes help to mold your personality. Quite often, attitudes are learned. Some popular phrases that demonstrate the magnitude of a good attitude are “Attitude = Altitude” (Figure 1-6) and “Attitude Is Everything.” Having a good attitude can help you to flourish both in your professional and personal lives. Your attitude can be a magnet that draws people toward you or a repellant that drives people away. Attitudes are infectious, which illustrates why employers work hard to find employees with good attitudes. Employers realize that it only takes one staff member onboard with a poor attitude to sour the whole team. On the contrary, staff members who possess positive attitudes will most often influence other staff members to be positive and to work in harmony with one another. One significant factor that influences our attitude is our emotions. Emotions can trigger our attitudes, especially repeated emotions. Take the woman who feels that all men are “jerks,” because she has been hurt by two bad marriages that ended in divorce. The repeated emotions of heartbreak and distrust have caused her to feel that all men are not to be trusted, thus creating a poor attitude toward men in general. To fix a problem, you must first admit that there is a problem. If an employer or instructor expresses concern with regard to your attitude (Figure 1-7), instead of becoming defensive about it, look inward and recognize that you may have a problem. A helpful practice that may assist in improving your attitude is to log instances in a notebook or diary of instances in which your attitude diminished. Explore possible triggers that cause your attitude to decline. Do you have a coworker, friend, or peer who causes your attitude to deteriorate? If so, separate yourself from that individual or discuss ways to improve the situation so that your attitude is not affected when you are around that individual.
FIGURE 1-7 Constructive criticism from your instructor may be a bit painful at the time you are receiving it, but it can help you from making errors in the future.
Look for the good in people instead of focusing on the bad. Realize that everyone is unique and that just because they do not share your same interests does not mean they are inferior or beneath you. Work hard to stay away from cliques and people who criticize others. Actions That Reflect a Positive Attitude The following is a list of actions that reflect a positive attitude to those around you:
FIGURE 1-6 A good attitude is essential to climb the ladder of success as a medical assistant.
Attitude
D
s Altitude e n i eterm
JOURNEY TO PROFESSIONALISM
❖ Extend greetings toward coworkers, supervisors, and patients. ❖ Smile often. ❖ Accept constructive criticism from those in authoritative positions. ❖ Be flexible in your thinking when things don’t necessarily go as planned.
Key #2: Dependability The term dependability means to be reliable or trustworthy. It starts with an internal mindset and works its way outward in the form of an action. Dependability is one of the most important keys to possess as a professional. Examples of actions that reflect dependability include the following: ❖ Show up for work on time. ❖ Give ample notice to your supervisor when you are unable to go to work. ❖ Return from breaks and lunch hours on time. ❖ Follow through with assigned tasks in a timely fashion. ❖ Work past your scheduled time off, when necessary. ❖ Go the extra mile to help your coworkers. To demonstrate the importance of dependability, consider this: When a potential employer calls a school to check a reference for a student, he rarely begins the conversation by asking about the student’s grade point average. The first question typically asked is, “How was the student’s attendance?” Remember, you are affecting the recommendation from your instructors whether you are present or not. If you have notoriously poor attendance, realize that you are not going to change overnight. Start off the beginning of your training program by being more dependable. If necessary, arrange for backup childcare and transportation before problems arise. Strive for perfect attendance as a personal goal. Statistics confirm that employers will select candidates with perfect or good attendance over candidates who possess fair or poor attendance, even if those candidates were academically outstanding.
Key #3: Tactfulness Tact is a character trait that is essential to demonstrate as a professional. You may have heard a friend call someone tacky or tactless. A person who possesses tact is sensitive to what is appropriate when dealing with other individuals, including the ability to act or speak without being offensive. During conflict, a tactful per-
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TOOL BOX
C R I T I C A L T H I N K I NG CHALLENGE You are about a third of the way into your training program. Your instructor has repeatedly stated that a reference is not a gift, but rather something that you have to earn. Your attendance has not been very good up to this point. You are now really starting to see the value of a good reference. 1. Is there anything that you can do to salvage your reputation with your instructor at this point in the program? 2. Do you think that your instructor should bend the truth with potential employers regarding your early attendance problems as long as you correct your attendance for the remainder of the program? Why or why not?
son is able to find a way to say what needs to be stated without coming across as harsh or rude. The other component of tact is presentation or the way you deliver the message to the receiver. It involves the tone of your voice as well as the body language you use. It is deciding when and where you will share the information and who will be present when the message is delivered.
TOOL BOX
FI E L D S M A R T S Never confront another employee in the heat of frustration. Give yourself time to cool down and think about what you are going to say and how you are going to say it. Location is just as important when confronting another employee. Avoid making the situation worse by embarrassing your coworker. Find a location where you can ensure privacy. Handle the situation the way that you would want it to be handled if you were on the receiving end. Figure 1-8 shows a picture of one employee confronting another employee in front of a patient. This type of behavior is unacceptable in a professional environment.
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staff members to question your integrity. Making false excuses for missing work will result in a loss of respect from coworkers and supervisors.
Key #5: Compassion
FIGURE 1-8 Never confront another employee in front of a patient. It is very rude and unprofessional.
The word confidentiality means to keep something secret or private. Patient information is considered confidential and must not be shared with anyone without the patient’s written authorization. Other privacy issues include comments made to you from a supervisor or other employee that are meant to stay private. A tactful person does not share private information with other individuals.
Key #4: Integrity The word integrity means to possess sound character. Truthfulness, honesty, and honor are all qualities of a person who possesses integrity. Medical assistants should demonstrate integrity at all times. Never give anyone a reason to doubt your integrity. Lying or taking things that do not belong to you will provoke office
TOOL BOX
F IEL D S M A R T S Avoid putting yourself in a situation where someone can question your integrity. Bending the truth, taking a coworker’s lunch or drink, or falsifying information are all ways that your integrity may be challenged. Be completely honest about the hours you record on your time sheet. Never lie to cover up an error. It may be costly to both you and the patient.
The term compassion means to show concern and empathy. Empathy is having the ability to put yourself in another person’s shoes. In the minds of your patients, compassion is paramount. If you were to suddenly become disabled, you would want your health care provider to do everything possible to make certain that all paperwork was properly completed so that you could receive your weekly benefits. Think about that when a patient “inconveniences” you by asking you to complete paperwork or asks you to make a phone call on his behalf. A compassionate person, even though he is busy, makes every effort to complete the request in a timely manner. Compassion shouldn’t stop with the patient; it should permeate to your coworkers as well. When you observe that a coworker is running behind schedule, ask if there is anything that you can do to help. Someday, he may return the favor.
Key #6: Initiative The term initiative means to take the lead or to work independently. Employers rely on their employees to start a procedure or process on their own and see it through to fruition. A good medical assistant will use observation and listening skills to expedite this process. It is hard to take initiative until you understand your role within in an organization. Instead of just standing or sitting at your station waiting for the provider to finish up with the patient, look for things that you can do while you are waiting, such as straightening up the reception room or filing some charts. On the other hand, the medical assistant must be mindful of boundaries. In eagerness to please your employer, you must never cross the line of your specific role. For instance, it is considered acceptable to anticipate that a provider is going to need a urine specimen when a patient complains of urinary symptoms, but it is not acceptable to perform any testing on that urine until you have received a direct order from that provider to do so.
The External Journey The second corridor in Figure 1-1 represented the external part of your journey toward becoming a professional. The external part of the journey involves the most physical work. The rooms in this corridor require you to take specific actions in order to better yourself
JOURNEY TO PROFESSIONALISM
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or to assist your patients. Figure 1-9 shows an illustration of the keys that are necessary to unlock the doors in this corridor of the journey.
Key #7: Education True professionals empower themselves with education (Figure 1-10). The more you know, the better you can serve your employer and patients. You must work hard to learn all you can during the educational process. Listen and adhere to the advice of your instructors. Academic and technical skills are very important, but so are the life experiences that your instructor shares. An instructor has already gone down the road before you, navigating through the rough spots, smoothing out imperfections, and advising you of the many bends and curves that lie ahead. Welcome constructive comments from your supervisors and other seasoned professionals. Their expertise can supply you with wonderful insight and save you a great deal of heartache and energy along the way. Education doesn’t and shouldn’t stop at the time of graduation. Get involved in professional societies and attend continuing education workshops, seminars, and conventions. Read professional journals and watch educational programming that can supply you with the latest health information so that you are better able to educate your patients.
Key #8: Good Communication Skills The medical assistant must possess strong verbal and written communication skills. As a medical assistant, FIGURE 1-9 These are the keys necessary to unlock the doors in the external corridor—education, communication skills, appearance, service, and credentialing.
Cred
Ed
entia
uc ati on
Se
Com
mu n Ski icatio n lls
rv
Appearance
ice
ling
FIGURE 1-10 Medical assisting students must empower themselves with education so that they can be the best they can be.
you will be in constant communication with other health care professionals, insurance representatives, and patients from all walks of life. Learning medical terminology is only part of the training that is necessary when developing professional language skills. Students must also learn proper English in addition to medical terminology. Pronounce words correctly so that the receiver can properly interpret what is being stated. Elimination of slang terms and profanity is a must when working in a professional environment. Good communicators are able to converse about many different subjects. Thus, it is important for the medical assistant to keep up with current events by reading newspapers and watching the news. A medical assistant should be well informed about many different topics so that he is able to appropriately respond to comments made during casual conversations. Because of the various emotions involved, discussion items to avoid include religion, politics, and those of a sexual nature that are not related to the patient’s medical history or condition. Written communications are just as important as verbal communications. A large percentage of the way you will communicate both inside and outside of the
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TOOL BOX
F IEL D S M A R T S When documenting a patient’s chart, never use a word that you do not know how to spell. If you do not know a synonym to use in its place, leave space in the chart and look up the word after you meet with the patient. Not only is the chart a legal document that can be used in a court of law, the opinion of your coworkers and supervisors may diminish as a result of misspellings or poor documentation.
office is through written communications. Documenting patient’s charts, sending faxes, and composing e-mail messages are just a few of the types of written communications that you will perform. Proper spelling is also essential when documenting the patient’s chart or sending out a correspondence.
Key #9: Good Appearance
good at phlebotomy, but if the patient looks down and sees that your nails are unkempt, you may never get the opportunity to prove your technical capabilities. Figure 1-11 shows two athletes that have taken great pride in selecting uniforms and shoes that match and look good. Their motto is, “Look good, feel good, play good!” The medical assistant can have a similar motto: “Look professional, feel professional, be professional!” (Figure 1-12). Professional appearance is about much more than the uniform. It is about the amount of sleep you obtain, the food you consume, and the way that you carry yourself. It is about walking into the patient’s room and earning their immediate respect because your uniform is clean, neat, and pressed. Your shoes are clean, your hair is neat, and you look rested. Your smile puts the patient at immediate ease and your straight posture and confident voice exude professionalism. Even though there can be some variance from facility to facility, Table 1-1 depicts typical standards in the industry for appearance.
Key #10: Service
The patient’s initial impression about you as a professional is based on your appearance. You may be very
The term service means to extend help to others. Figure 1-13 illustrates a medical assistant consoling a patient who is fearful about some tests that need to be
FIGURE 1-11 These athletes take pride in the way that they
FIGURE 1-12 Medical assistants should also take pride in the
look.
way that they look.
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TABLE 1-1 Professional Appearance Table ITEMS
ACCEPTABLE
UNACCEPTABLE
Personal hygiene
Shower or bathe prior to shift. Use deodorant whether or not you think you need it. Brush teeth, floss, and use mouth rinse. Use breath mints throughout the day to help keep breath fresh.
Body odors. Halitosis. Wearing fragrances such as perfumes or aftershave lotion. Having the aroma of alcohol or cigarettes coming from your body or clothes.
Uniform
Wear scrubs or other styles of uniforms that are in alignment with the rules of the facility in which you are employed. Keep uniforms clean, neat, and free of wrinkles.
Wearing uniforms that are not in alignment with the facility standards. Wearing unprofessional clothing underneath your uniform such as T-shirts with logos or sweatshirts underneath scrub tops. Wearing uniforms that have stains or that are wrinkled.
Shoes/hosiery
Keep shoes and hosiery clean. Wear white duty shoes or white athletic shoes with little or no color. Wear white socks or white nylons underneath shoes.
Wearing dirty shoes or open-toed shoes. Wearing colored socks or not wearing any socks. Wearing shoes that are not the correct color.
Jewelry
Use very simple jewelry or no jewelry. Limit jewelry to one simple ring or wedding set per hand.
Wearing facial, tongue, or multiple ear piercings. Wearing earrings that are very large such as large hoops or earrings that dangle. Wearing necklaces, bracelets, and anklets.
Use of a watch with a second hand is encouraged. Tattoos
Whenever possible, cover tattoos with clothing or a special makeup that helps to conceal them.
Leaving tattoos exposed.
Makeup
Use of light foundations, light blush, and light shades of lipstick is considered professional.
Wearing makeup that is very dark against your natural pigment. Wearing dark shades of lip color or eye makeup.
Hair color and hair styles
Maintain a hair color that is one of the more natural hair colors. Tie back hair when longer than shoulder length. Keep beards well-groomed.
Wearing unnatural hair colors or streaks within the hair, such as, pink, purple, etc. Wearing hair longer than shoulder length without tying it back.
Nail care
Keep nails well-manicured and short enough that they do not extend above the fingertip.
Nails that extend beyond the fingertip. Dirty nails, darker shades of nail polish, or nails with chipped polish. Artificial nails or overlays, which can be a breeding ground for microorganisms.
Identification badge and professional pins
Wear with your uniform.
Not wearing an identification badge.
Posture
Stand straight, with shoulders back and chin up.
Slouching with shoulders rolled forward and head bent downward.
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P A T I E N T P E R S P E CT IV E I am often nervous about having my blood drawn or receiving an injection. I want to know that the person performing the procedure is indeed qualified to do so. When the person performing these types of procedures has a certifying credential listed beside his name, it makes me feel more secure and at ease about having the procedure performed.
FIGURE 1-13 The medical assistant should be prepared to console patients who are fearful or hurting.
performed. The field of medical assisting is a service profession; serve your employer and patients to the best of your ability. Serving others often involves listening with your ears, eyes, and heart. It is extending a hug when someone is hurting and going the extra mile to institute modesty for your patient. It is allowing the alcohol to dry before inserting the needle and making the telephone call before the patient has to call you. The benefits and rewards of serving others are knowing that you have made a difference in the lives of your patients. To serve is a privilege!
Key #11: Credentialing Becoming credentialed as a medical assistant demonstrates to your patients and supervisors that you are worthy to be working in the capacity in which you have been entrusted. Credentialing validates that you have been successful in attaining the educational components that are necessary for the duties that you perform. There are several terms that are used to validate one’s knowledge of a particular profession. The terms that are used most often are licensed, registered, and certified. Licensing refers to a legal document that permits or authorizes a person to perform a specific task or tasks. You must be licensed to practice medicine. Examples of professionals who must be licensed to practice medicine include physicians, dentists, and nurse practitioners. Currently, no state offers licensing opportunities
for medical assistants. Certification is a term that signifies that one has fulfilled the necessary requirements of a specific organization to perform specific tasks. This is usually accomplished through some kind of a testing. Registration is a term that means to enroll one’s name in a register, based on successful completion of a specific program and/or ability to pass an examination designed specifically for that particular specialty. The earlier part of the chapter discussed certifying organizations for medical assistants. The two major organizations that credential medical assistants are the AAMA and the AMT. The AAMA offers the Certified Medical Assistant (AAMA) credential. The initialism of the credential is CMA (AAMA). The emblem for the AAMA can be found in Figure 1-14a, and the CMA (AAMA) pin can be found in Figure 1-14b. To sit for CMA (AAMA) exam, you must be a graduate of an institution that is accredited by the Accrediting Bureau of Health Education Schools (ABHES) or the Commission on Accreditation of Allied Health Education Programs (CAAHEP). The AMT offers the Registered Medical Assistant (RMA) credential. Figure 1-15a illustrates a photograph of the AMT logo and Figure 1-15b illustrates a photograph of the logo that is found on the RMA pin. To sit for RMA exam you must provide documentation for one of the following: you are a graduate from an institution accredited by one of the accrediting bodies listed above; you received formal training from the military; or you have worked in the industry for a minimum of five years. There are other certifying bodies for medical assistants as well. Refer to Table 1-2 to learn more about other certifying organizations. The medical assistant can also take various clinical specialty exams based on the accreditation status of the
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FIGURE 1-15a AMT logo (Courtesy of the American Medical Technologists.)
FIGURE 1-14a AAMA logo (Courtesy of the American Association of Medical Assistants.) FIGURE 1-15b RMA logo (Courtesy of the American Medical Technologists.)
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school. Different specialty areas in which credentialing is available include phlebotomy, physician office laboratory, and EKGs. Some medical assistants may also be interested in taking classes for a special type of x-ray licensing. X-ray licensing will vary from state to state. A limited radiography certificate generally allows the medical assistant to take limited x-rays in ambulatory care centers. Table 1-2 lists some of the different credentialing opportunities for medical assistants as well as the name and address of the organizations that offer the credentialing. Arrange a meeting with the institution’s medical assisting program director or other instructors within the program to determine which credentials you qualify for based on the school’s accreditation status and the academia presented within the program.
FI E L D S M A R T S You will be competing for positions with members of your own class and from competing schools. These candidates will each be working toward or possess their own set of credentials. It is not only important that you gain credentials, but it also equally important that you have a basic knowledge of the various credentials available, so that you can explain and sell your own credential(s) at the time of your interview. Prospective employers may be confused about the various types of credentials that come across their desk and may ask you to explain why your credential is equal to or better than another candidate’s credential.
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SITE CHECK As an insurance surveyor, I will check employee files to ascertain that the employees working in specific capacities have the credentials necessary to perform the tasks associated with each specific job title.
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TABLE 1-2 Credentialing Opportunities for Medical Assistants
NAME OF ORGANIZATION
ADDRESS OF ORGANIZATION
TESTING REQUIREMENTS
American Association of Medical Assistants (AAMA)
20 N. Wacker Dr., Ste. 1575 Chicago, IL 60606 (800) 228-2262 www.aama-ntl.org
Must have graduated from a CAAHEP or ABHES accredited institution.
American Medical Technologists (AMT)
710 Higgins Road Park Ridge, IL 60068 (847) 823-5169 www.amt1.com
Must have graduated from a CAAHEP or ABHES accredited institution or have had related military training or a minimum of five years of field experience.
National Center for Competency Testing (NCCT)
7007 College Blvd., Suite 250 Overland Park, KS 66211 (913) 498-1000 or (800) 875-4404 www.ncctinc.com/
Programs that are accredited through a national or regional organization.
American Registry of Medical Assistants (ARMA)
69 Southwick Road Westfield, MA 01085 (800) 527-ARMA www.arma-online.org
Most programs accredited through national or regional bodies; candidates who have worked in the field for a minimum of five years or who have related military training.
National Healthcareer Association (NHA)
134 Evergreen Place, 9th Floor East Orange, NJ 07018 (800) 499-9092
[email protected]
Must have a high school diploma or equivalency and successfully completed an NHA approved training program or worked in the field of certification for a minimum of one year.
American Society for Clinical Pathology (ASCP)
2100 West Harrison Street Chicago, IL 60612 (312) 738-1336
[email protected]
High school graduate or equivalent and successful completion of RN, LPN, or other acceptable accredited allied health professional/occupational education, which includes 100 successful venipunctures, 25 successful skin punctures, and orientation in a full-service laboratory.
American Society of Phlebotomy Technicians (ASPT)
P.O. Box 1831 Hickory, NC 28603 (828) 294-0078 www.aspt.org
Will vary with each type of certification; must be a member of the ASPT to participate in all exams.
Chapter Summary Making the transition from student to professional will require a great deal of work on your part. It will require you to perform an honest assessment of your character traits and to make the necessary adjustments. The person you are today shouldn’t be the same person that walks across the stage during the graduation ceremony. Family members, peers, and instructors should notice differences in your demeanor and the way that you conduct yourself as you progress throughout the training process. Work hard throughout the program to earn the references that are essential in obtaining the job of your dreams.
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CREDENTIALING OPPORTUNITIES AVAILABLE HOW OFTEN TESTING IS ADMINISTERED AND LOCATION OF TESTING CENTERS
(WILL VARY ACCORDING TO EACH INSTITUTION’S ACCREDITATION AND TRAINING REQUIREMENTS)
The dates and times tests are given will vary with sites administering the exams. Tests are given at Prometric Testing Centers. Contact the AAMA for a listing of approved sites.
CMA (AAMA)-Certified Medical Assistant through the AAMA
The times tests are given will vary with sites administering the exams. Tests are given at Pearson VUE locations throughout the country and other sites approved by the AMT.
RMA-Registered Medical Assistant COLT-Certified Office Laboratory Technician RPT-Registered Phlebotomy Technician
Will vary with each testing center or institution; several testing centers and institutions are located throughout the nation.
NCMA- National Certified Medical Assistant NCPT-National Certified Phlebotomy Technician NCET-National Certified ECG Technician
No testing is required.
RMA-Registered Medical Assistant
NHA exams are given at different locations throughout the country. Dates will vary. Call the NHA for location and date information.
CPT-Certified Phlebotomy Technician CET-Certified EKG Technician CCMA-Certified Clinical Medical Assistant CMLA-Certified Medical Laboratory Assistant
Test is given at Pearson VUE locations throughout the country; dates and times will vary.
PBT-Phlebotomy Technician
Testing is given at different locations throughout the country and different dates; contact the ASPT for details.
EKG Technician Phlebotomist
Empowering yourself with education is a great start toward becoming a professional, but you will need to continue your education once you finish your training by attending seminars, workshops, and conventions through one of the professional societies for medical assistants. Credentialing solidifies your position in the professionalism arena. It helps to confirm your knowledge of the industry and tells potential employers and patients that you have a right to perform the tasks assigned to you. Employers will have greater respect for candidates that go the extra mile to achieve credentials.
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FIELD APPLICATION CHALLENGE You are a medical assistant who works for a midsize family practice. While you are cleaning the examination room, your coworker, Sarah, enters the doorway and asks to speak with you for a moment. Sarah tells you that she believes that another coworker, Kim, lied about being ill today and that the only reason Kim didn’t come in is because she is lazy and doesn’t want to help on “file purging day.” Sarah ends the conversation by telling you that she doesn’t mean to gossip but that she really feels that Kim is a poor worker and that she is tired of pick-
ing up the slack for her. You personally have always found Kim to be quite helpful and honest. 1. Do you think that it is right for Sarah to voice her concerns about Kim to another coworker? 2. What is an appropriate way to respond to Sarah’s accusations? 3. Do you feel that you should share this information with Kim when she returns? Explain your response.
Chapter Assessment 1. The ability to place yourself in someone else’s “shoes” or situation is known as: a. sympathy. b. empathy. c. imitation. d. projection.
a. Tell Sandy that you saw her take the Demerol. b. Tell one of the other staff members that you witnessed Sandy take the Demerol. c. Tell the supervisor that you witnessed Sandy take the Demerol. d. Say nothing at all.
2. All of the following are keys to unlocking the door to professionalism except: a. attitude. b. education. c. appearance. d. talent.
5. Each of the following organizations credential medical assistants except the: a. AAMA. b. ASCP. c. NCCT. d. AMT.
3. Which of the following does not contribute to a professional work environment? a. Gossip b. Initiative c. Helpfulness d. Integrity
6. Which one of the following organizations does not provide a credential in phlebotomy? a. AMT b. NCCT c. ASPT d. AAMA
4. While serving your externship, you observe Sandy—one of the employees at the externship site—slip an ampule of Demerol into her lab jacket. She doesn’t record it into the narcotics log and she has no idea that you saw her take it. The next day the office supervisor calls a meeting and tells everyone that the narcotics count was off last night and that they are missing some ampules of Demerol. What of the following is the best course of action?
7. What is the only credentialing organization for medical assistants that does not require testing for credentialing? a. ARMA b. AAMA c. AMT d. NCCT
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Web Activities 1. Visit the AAMA Web site at www.aama-ntl.org. Click on the section entitled “Medical Assistanting.” Next, click on “CMA (AAMA) Profiles.” Select one person featured in the profile screen that stands out. What is unique about this person? Do you have any similarities with this person? What is unique about the job that they possess? Would you like a job in the same type of practice as this featured CMA? 2. Visit the AMT Web site at www.amt1.com. List all of the different credentials that can be attained through this professional organization. From that list, what credentialing exams do you qualify to take following graduation? Are there any that you can take once you have been in the field for a while?
CONNECTION Using your StudyWARE CD-ROM: ❖ Complete the Flash Cards activity for this chapter. ❖ Complete the Quiz for this chapter in Test Mode.
THE DVD LINK On your StudyWARE CD-ROM, go to the DVD Challenge for this chapter. View the DVD clip and respond to the following questions: 1. What character traits does Dee lack that will prevent her from being a successful professional if she doesn’t make changes before graduating? 2. Are there any similarities between you and Dee? 3. Do you think that Dee’s instructor is going to be able to give her a good reference based on what you saw in the clip? 4. What changes do you need to make in order to be a successful professional?
C H A P T E R
Organization and Time Management in the Medical Office Chapter Outline Becoming Organized While You Are in School Taking Charge of Your Educational Experience Getting the Most Out of Your Study Time Preparing for Competency Testing Getting Acclimated to Your New Work Environment Locating Where Items Are Stored Interviewing Providers Who You Will Be Working With Setting Up Your Workstation and the Clinical Area Supplies and Equipment for the Work Environment Organizing Patient Exam Rooms Setting Up a Pending File Workstation
Daily Procedures That Clinical Staff Members Perform Opening Procedures for the Clinical Medical Assistant Closing Procedures for the Clinical Medical Assistant Reviewing and Maintaining Patient Charts Creating and Implementing Daily Task Lists Working the Floor of a Medical Office Clinical Assisting and Time Management Issues Performing Routine Maintenance on Clinical Equipment
2 Essential Terms acclimate callback competency desktop organizer drawer organizer out guide pending preventative health screening protocol provider query task box task list workstation
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KEY COMPETENCIES Performing Routine Maintenance on Clinical Equipment
CAAHEP
ABHES
III.C.3.c.4.b
VI.A.1.a.6.b
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Developmental Objectives After completing this chapter, you should be able to: 1. Correctly spell and define the essential terms. 2. List different ways that the medical assistant can organize a study area at home to make it more efficient. 3. Describe how to properly prepare for the performance of clinical competencies. 4. List three ways that the medical assistant can become better acclimated to the medical office. 5. Explain the importance of reading the office policy and procedure’s manual. 6. List supplies that can help to create and maintain an organized workstation. 7. Discuss the importance of setting up a pending workstation. 8. Discuss the importance of dividing the pending work file station into specific categories. 9. List steps that can be taken before patients arrive to save time when patients are present. 10. List common procedures for opening and closing the office. 11. Describe the importance of creating and maintaining a daily task list. 12. List common tasks associated with working the floor of a medical office and to classify where each task falls on the priority schedule. 13. List steps for maintaining equipment in the office.
Introduction Possessing good organization and time management skills will assist you in every phase of your life. These skills will assist you in running an efficient home, being a successful student, and having a successful career as a medical assistant. The medical field can be quite demanding. Along with all your floor responsibilities, you will have a large amount of paperwork that will need to be tended to throughout the course of each day. The majority of paperwork will need to be handled the same day that you receive it, which can cause you to run behind in your schedule and promote feelings of anxiousness and overall frustration. The training process can be equally as demanding. There are tests to be taken, competencies to perform, and homework to be completed. If you do not learn early how to organize and pace yourself, you may become discouraged and give up before reaching your goal. This chapter will present you with valuable information for getting the most out of your educational training and will provide you with tips that will assist you with organization and time management skills upon entering the industry.
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BECOMING ORGANIZED WHILE YOU ARE IN SCHOOL Good organizational skills will assist you in the classroom, in the laboratory, and during your study time at home. Students who lack discipline and have poor organizational skills usually do not perform nearly as well as those students who do. Students who struggle with organization seldom are prepared to take tests or perform competencies and are always rushing to get caught up. Frequently they feel anxious, inadequate, and discouraged. Developing time management and organizational skills is not something that just happens overnight. You will need to continuously work to develop these skills until they become habits. If you are someone who struggles with overall organization and time management, start now to develop these skills so that by the time you graduate, they will be part of your normal routine.
Taking Charge of the Educational Process If you do not take charge of your life, your life will take charge of you. It is important for you to take charge of your learning as well. You might start by purchasing a large desk calendar and placing it within your work
area at home. Some students find large desk calendars work better than pocket planners or computer calenders because they are highly visible. Create a calendar matrix by writing in test and quiz dates, competency dates, and the due dates of special projects. Determine how much time is going to be necessary to prepare for each task and pencil in study time to accommodate each task. Do your best to adhere to the tasks on the schedule. Figure 2-1 shows an example of a study matrix penciled in on a desk calendar. Organize your study area so that items are readily accessible. Make certain that your desk or workstation has a stapler, staples, paperclips, a hole punch, and paper. Have a stock supply of computer cartridges and printing paper so that you don’t have to stop what you are doing when working on home assignments. Go through book bags and notebooks daily to remove any unnecessary items such as trash or old assignments. If you want to retain graded assignments, place them in separate notebooks with dividers identifying each section.
Getting the Most Out of Your Study Time It is important that you keep up with your instructor by reading the assigned information prior to class time. Highlight important reading content such as bulleted
FIGURE 2-1 A large desk calendar can keep the medical assisting student on track and organized.
October Sunday
Tuesday
Monday
1
2
3
8
9
10
Study for Clinical Clinical Test 1, Study for the over chapters, following comps: Test Handwashing 1, 2, and 3 and Interviewing a Patient
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4
Competency Testing over Handwashing comp and Interviewing a Patient
11 Work on Research Paper
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Clinical Test #2, Research Paper Study for Due Clinical Test #2, over chapters over chapters 4, 4,5, and 6 5, and 6
Friday
Thursday
Wednesday
Saturday
5
6
12
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Work on Research Paper
18Study for the following comps: Disposal of Biohazardous Waste, and Disinfection of an Instrument
Work on Research Paper
19 Competency 20 Testing: Disposal of Biohazardous Waste, and Disinfection of an Instrument
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items, words that are in bold print or italics, and all normal values. Jot down questions regarding reading material that you do not fully understand so that you may address the questions during the next scheduled class. Take good notes during lectures and pay attention to cues from the instructor regarding information that is important. Listen intently to common errors, tips, and anecdotal information given by your instructor. This will help you immensely when you practice procedures in the laboratory. Watch each related DVD scene and complete all software exercises so that you become knowledgeable about all aspects of each skill, including how to perform it, why you are performing it, what may happen if you perform it incorrectly, and how to think through obstacles that may occur. Review notes following the lecture to make certain that you understand them. Start a glossary notebook that identifies key terms within each chapter for easy referencing. Review chapter summaries and make good use of downtimes, such as waiting for a bus or waiting for a load of laundry to finish. Setting up flashcards is a very good way to commit clinical information to memory. Make a flashcard for all normal values, instruments, tray setups, and abbreviations. You will need this information throughout the entire program, so review your flashcards often. If you have a certification review book, complete the review book as you go over related material. Figure 2-2 illustrates a medical assisting student highlighting a review book as part of her regular study routine. Write brief notes in the book that will help spark your memory upon completion of the program. This will help you get a head start on studying for the certification test while information is fresh and help you commit the information to memory.
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CR ITI C A L TH I N K I N G C H AL LEN G E Your school does not provide a certification review book or does not distribute one until the end of the program. What are some options for you to help you review for the test while you are still in school?
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FIGURE 2-2 Using your certification review book from the beginning of the program will help you understand and retain the information you learn. When you start reviewing for the test, it will be much easier.
Preparing for Competency Testing The term competency in this sense refers to a checklist that is used by an evaluator to determine one’s knowledge of a specific skill. Accredited programs require students to pass a predetermined list of competencies in order to graduate. Think of each competency or “comp” as a test. Practice the procedure several times so that you are not only competent in the skill, but you build confidence as well. Study the comps, tips, and anecdotes the night prior to testing so that everything is fresh in your mind. While preparing for and performing the competency consider the following: 1. Presentation Style: What type of mindset do you have as you attempt the competency? Do you think of yourself as a student or as a medical assistant? You should think of yourself as a medical assistant. You need to look like a professional, talk like a professional, and treat your lab partner as though she were an actual patient. Put extra effort into your appearance (Figure 2-3) on comp days and make a conscious effort to speak and act like a professional while you are performing the competency. It may feel a bit awkward at first but eventually the awkwardness will wear off and you will take on the characteristics of a true professional. 2. Performance Steps: You will need to perform each step precisely and in the correct order listed on the competency form. Do not attempt competency testing until you have each step completely mastered.
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the process how to manage your time well and organize your work environment. The remainder of this chapter will focus on workplace organization and time management.
GETTING ACCLIMATED TO YOUR NEW WORK ENVIRONMENT
FIGURE 2-3 The medical assisting student checks her appearance before leaving the house to make certain that she looks especially professional for her competency testing later in the day.
This may take several practices. As you perform the steps, think about your environment. Are items set up in a logical order? Are you cleaning up as you go along? Does the work space look clean and organized? 3. Time Management: Are you able to perform the competency in the time constraints listed on the competency form? The best way to improve in this area is to practice, practice, practice. 4. Accurate Documentation: The majority of comps will entail some form of documentation. Performing the skill is only half of the procedure; documenting the procedure within the chart or onto special logs or forms is the other half. You must take as much pride in your documentation as you do in performing the skill. 5. Unplanned Obstacles: Things don’t always go as planned. Your instructor might intentionally throw some obstacles your way during the competency testing or some unplanned event may occur. Are you prepared to handle those events? Do not be too hard on yourself if you have to repeat a competency. If you are going to make an error, it is best to make it while you are still in the training process. It is the instructor’s responsibility to point out errors so that you don’t repeat them upon entering the field. It is your responsibility to understand why you made the error and to make the proper adjustments so that you do not repeat the same error again. Good work ethic and organizational skills will help you attain success in all aspects of life. Learn early in
One of the most difficult challenges that you will face in the medical office is learning how to organize yourself and the workstation so you are efficient with the provider’s time, the patient’s time, and most importantly, your time. Performing technical skills are only part of the tasks that you will incur on a daily basis. You may also be responsible for calling in prescriptions, setting up outside diagnostic testing, and performing other tasks for the provider. Learning how to organize your workplace environment and gaining knowledge of which tasks take priority are essential skills for creating a pleasant and efficient work setting. Time management and workplace organization are difficult tasks to master when working in any new environment but they can be attained rather quickly by learning the tricks of the trade. Providers lose patience when staff members cause the schedule to run behind due to inefficiency and poor time management. Observe how other medical assistants set up their workstations. Look for similarities, but also notice the differences. What makes one workstation better than another? Organizational skills are somewhat inherent, meaning that some people are just born with a talent for organizing; however, organizational skills can be acquired if you are willing to work at them. Think about the adage, “A place for everything and everything in its place.” If you live by that rule, organization is much more easily achieved. You can lose precious time each day just looking for items because you do not take the time to return items to their proper location. When you start a new job, you will want to take some time to acclimate yourself to the policies and procedures of that particular office. The term acclimate means to become accustomed to a new environment or situation. Of course, you will want to start by reading the office policy and procedure manuals. The information found in these manuals can save you many questions and a great deal of time if you will take the time to read them. Take notes on information that affects daily operations such as opening and closing procedures, the policy for disposal of biohazardous wastes,
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F IEL D S M A R T S Before attaching items to a wall, check with your supervisor to see if it is acceptable to do so. Some businesses will allow you to use pushpins but not tape to hang items. Whenever possible, use bulletin boards to display items so that you do not risk damaging the wall.
phone policies, etc. Other policies may include dress code, the office’s protocol for calling in sick, and the company’s privacy policy. If it is not the policy of the office to give each employee their own set of manuals, create an abbreviated version for yourself. Insert procedures and policy information within a notebook using sheet protectors and place them on a shelf so that they are easily accessible. You may want to display certain information such as opening and closing procedures on a wall or bulletin board. Whenever you display information, make it look appealing. Fasten the item to a piece of construction paper and neatly attach it to the bulletin board or wall. When you no longer need the information or it starts looking tattered, immediately remove or replace the item.
Locating Where Items Are Stored Spend a good amount of time during your first couple of days in the office learning where everything is located. Study the setup of each exam room, each supply cabinet, medicine room, and laboratory. Observe where oxygen and other emergency equipment and supplies are stored. Learn where administrative supplies are kept such as rubber bands, tape, and staples. You may want to keep a notebook that lists where these supplies are kept until you have an opportunity to familiarize yourself with their locations.
Interviewing Providers Who You Will Be Working With Every office has different policies regarding provider assignments. The term provider used in this context refers to the physicians, physician assistants, and nurse practitioners who work in the practice. Some practices assign one medical assistant per provider. Other practices have a rotating schedule so that each medical assistant works with every provider in the practice. Find out the preferences of the providers with whom
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you will be working and take good notes. Figure 2-4 illustrates a medical assistant talking to the provider about her particular specifications for certain examinations. Ask questions such as: 1. Do you want patients disrobed for particular exams and procedures? Do you like to meet with patients before they disrobe? 2. Do you have protocol that should be followed for certain types of patients or exams? (Protocol refers to a set of guidelines that should be instituted based on office policy and may include urine testing for pregnant patients, setting up specific trays for various procedures, and disrobing instructions based on symptoms.) 3. What is your policy regarding callbacks? What types of patient calls do you want transferred directly to you? Is there a telephone screening manual for calls that are sent back to the medical assistant? If not, what is the protocol for handling sick calls? 4. What are my responsibilities during an office emergency? 5. Do you have any additional requests or suggestions that can assist me in becoming more efficient?
SETTING UP YOUR WORKSTATION AND THE CLINICAL AREA A workstation is an area in the office supplied with equipment and furnishings for one person. Workstation setups will vary from one office to the next. Some
FIGURE 2-4 The medical assistant interviews the provider to learn the standard protocol for particular kinds of exams and procedures.
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medical assistants will have their own office or desk, while others will only be given a small cubicle or chair with a little bit of counter space. It is important to organize your area so that you can maintain efficiency and create an environment that is pleasant. Figure 2-5 illustrates both a disorganized as well as an organized workstation.
Supplies and Equipment for the Work Environment Start by making a list of all of the supplies that you will need to perform your job. Find out the policy of the office regarding desk and office supplies. Some offices will allow you to order whatever you need from a supplier. Other businesses will limit the amount of supplies and desk items that you can order and will only allow you to order the bare essentials. In the latter instance, you may want to purchase some of your own equipment and supplies to help create and maintain workstation organization. Even if you carry some of the financial burden for purchasing these supplies, it will be well worth it in the long run. Supplies and forms that are necessary to create and maintain an organized work environment include: 1. Forms: You will be using forms on a daily basis to perform your job. Place the forms in individual manila folders and suspend them in hanging files so that they are readily accessible. Types of forms usually stocked by clinical staff include progress notes, advance directives, referral forms, lab requisition forms, return to work excuses, problem lists, immunization fact sheets, and other patient edu-
cation handouts. Each week, inventory your forms and replenish forms that are running low. 2. Desk Supplies: These include pens, pencils, highlighters, a stapler, a staple remover, scissors, a hole punch, a daily organizer, a desk calendar, rotary or index files to place frequently called numbers, paperclips of all sizes, rubber bands, tape and a tape dispenser, correction fluid, index cards, a ruler, labels, Post-It Notes, and pads of paper. 3. Desktop Organizers and Drawer Organizers: Place desktop organizers such as file folder holders, card holders, monitor stand, letter trays, and pen and pencil holders on top of the desk (Figure 2-6). Use drawer organizers to keep drawers organized. If you have limited desk and drawer space, consider using wall file organizers that have several compartments for storage (Figure 2-7). This will keep your desk from becoming cluttered and disorganized. 4. Filing Cabinet: A filing cabinet may be used for common forms and stock supplies of desk items. Items such as printer cartridges, batteries, and printer paper may also be kept in the filing cabinet.
Organizing Patient Exam Rooms In most offices, providers are assigned a specific number of rooms. This usually ranges from two to three rooms per provider and will depend greatly on the size of the facility and the number of patients that are seen by each provider. Whenever possible, the medical assistant should set the rooms up so that they are identical to one another. All exam room drawers, counter tops, and cabinets should be set up and stocked exactly the same from one room to the next. This will
FIGURE 2-5 Medical assistants should take great pride in keeping their workstations clean and organized.
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FIGURE 2-6 Workstation organization can be better maintained by using desktop organizers.
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up an area for the provider that temporarily houses patient files that are awaiting tasks to be performed such as reviewing patient lab and diagnostic reports or approving prescription refills. Refer to Figure 2-9 for a picture of a “pending file workstation.” This workstation or area divides patient FIGURE 2-8 Examination room drawers should be stocked the same charts into specific from room to room and should be categories according well organized. to the nature and priority of the pending work. Other categories of pending files may include patient queries and queries from other health care providers. The term query means to make a request for information. Additional queries may come from the billing office, insurance companies, or the patient’s attorney. These queries will usually require some type of task to be performed such as a phone call or written response to
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FIGURE 2-7 If you are limited in desk and drawer space, the addition of a wall organizer may provide the space you need to maintain structure and organization.
promote quicker memorization of where items are located. Labels may be placed on drawers or cabinets so that anyone using the room will be able to locate and retrieve items quickly. Refer to Figure 2-8 for a picture of a well stocked and organized exam room drawer.
Setting Up a Pending File Workstation The term pending means to await or something that is to occur. Pending files in the medical office refer to files that are awaiting a task to be performed. The clinical medical assistant may be responsible for setting
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New medical assistants need to be careful not to step on anyone’s toes when setting up their workstation and examination rooms. If several medical assistants sit at one station, be certain that you know where your space starts and ends. Never violate another person’s workstation space. Do not borrow any items unless it is absolutely necessary. Return any borrowed items immediately. Stocking your station properly in the beginning will alleviate the need to borrow items from coworkers. Some facilities have more than one provider using a set of exam rooms. If you share rooms with other medical assistants, do not make any changes without checking with the supervisor and other medical assistants first. When the time is right, share your ideas with all staff members that share the room and ask for their input as well.
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FI E L D S M A R T S The smart medical assistant will work on pending files and callbacks throughout the day; however, the medical assistant cannot complete her work until the provider completes her work. Providers that wait until the end of the workday to start working on pending files will not only extend the time that they need to stay to complete the necessary tasks, but the medical assistant’s time as well. Arrange a meeting with the provider to discuss ways in which you both can be more efficient with your time. Whether or not the provider “buys in” to your suggestions will be largely related to the way the information is presented. Avoid being accusatory, critical, or condescending. The main emphasis should be geared toward time and cost saving tips for the company.
FIGURE 2-9 A pending file workstation helps to organize charts that have pending tasks so that both the medical assistant and provider can organize and prioritize pending work.
the patient or facility requesting information. Efficient providers will check the files that are stored in this area throughout the day and perform associated tasks that are related to the query. In many instances, the provider will give the chart back to the medical assistant with an attached task. The medical assistant will perform the task, which usually consists of making a phone call to the patient, calling in a prescription, faxing reports to the hospital, etc. These tasks are sometimes referred to as callbacks because of the many phone calls associated with them. Once the medical assistant is finished with the file, it should be placed with the other charts to be filed. Table 2-1 lists common categories for files with pending tasks and depicts their usual order of priority.
DAILY PROCEDURES THAT CLINICAL STAFF MEMBERS PERFORM The clinical medical assistant usually has many tasks to perform throughout the day. Common tasks include: 1. Opening and closing procedures 2. Reviewing and maintaining patient charts
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H I PA A PAT R O L When calling patients to discuss test results, make certain that you are speaking directly with the patient. If the patient is unavailable, do not give out any results or information unless you have a signed privacy statement from the patient stating that it is okay to give the information to the person with whom you are speaking.
3. Writing daily tasks lists 4. Working the floor 5. Working on pending files
Opening Procedures for the Clinical Medical Assistant Opening procedures will vary from one office to the next. Be certain to write or make a copy of opening procedures and place them in a convenient location so that you can refer to them each morning.
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Electronic medical records (EMRs) reduce the amount of time spent in performing pending tasks associated with patient files. The initial work of retrieving the chart, attaching the query, and placing it in the provider’s pending file workstation has been eliminated. With some EMR software programs, the medical assistant will simply bring up the patient’s file in electronic format, type the query or task to be completed onto the progress note, and click on the appropriate provider’s name at the bottom of the progress note, sending it directly to the provider’s electronic “task box.” A task box used in this context refers to an electronic messaging system within the EMR that alerts users of
TABLE 2-1 Prioritization of Pending Tasks PRIORITY LEVEL
NAME OF CATEGORY
1
Abnormal or Critical Lab and Diagnostic Test Results
2
Phone Reports or Questions That Require a Prompt or Same Day Response (questions from nursing homes, patients, hospitals, etc.)
3
Prescription Refills
4
Phone Reports or Messages That Do Not Require an Immediate or Same Day Response (positive progress report from patients, questions not related to the patient’s health, etc.)
5
Billing, Insurance, and Attorney Queries
Disclaimer: Anything that is classified as an emergency should be handled immediately!
tasks that need to be performed. All members of the medical team have their own electronic task box. If the task is urgent, the sender will click on the appropriate tab and a priority symbol will be displayed, alerting the receiver of the priority of the task. Office staff members should work on electronic tasks throughout the day. Examples of electronic tasks include: e-mailing prescriptions to the patient’s pharmacy, e-mailing consultation reports to outside provider, downloading and reviewing patient lab or x-ray results, responding to patient e-requests, and responding to requests from the provider to perform nonelectronic tasks such as calling patients with test results or prescription changes.
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C R I T I C A L T H I N K I NG CHALLENGE It is the end of the day and everyone has gone home except for you. The provider has finished going through the files in the pending file workstation and has left the office. You still have a couple of callbacks to perform. You are trying to reach a patient who had a Pro-Time (a lab test that measures how well the blood is clotting). The Pro-Time is at a critical level and the provider has instructed you to call the patient and have her change the amount of Coumadin (blood thinning medication) that she is taking. You have tried calling the patient’s home phone number but no one is home. There is an answering machine, but the privacy statement does not specify that you can leave results on the answering machine. The patient does not have a cell phone. 1. What are your options?
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Opening procedures that are specific to members of the clinical team may include: 1. Turning off the alarm system if you are the first to arrive 2. Turning on lights throughout the clinical area 3. Turning on equipment in the lab and x-ray rooms 4. Unlocking the drug room 5. Stocking patient rooms 6. Updating charts for patients scheduled the same day 7. Performing lab controls at the beginning of the day 8. Pulling off lab and diagnostic reports that may have come across the printer or fax machine throughout the night. See information below. When using paper charts, pull off lab reports and faxes that came in throughout the night and attach them to patient charts. Figure 2-10 shows a medical assistant pulling off lab reports from the lab printer. These should be placed in the provider’s pending file workstation for review. If using electronic charts, the medical assistant may need to download lab reports from the lab’s Web site and send the reports or messages to review the reports to the provider’s electronic task box.
Closing Procedures for the Clinical Medical Assistant Closing procedures will also vary from one office to another but will usually be the opposite of what you do upon arrival to the office. Closing procedures for clinical staff may consist of the following:
FIGURE 2-10 The medical assistant pulls off the lab reports first thing in the morning and throughout the day.
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FI E L D S M A R T S Some offices have meetings that may be referred to as “morning huddles” before the day begins. The huddle may include the entire office staff or just specific members of the clinical team. The provider will go through the list of patients coming in that day and may give specific instructions that are to be followed for particular patients. The team may review other duties that need to be completed and assign specific team members with various tasks. Many times the huddle ends with a positive thought or an inspirational message from the provider or another team member. This type of interaction helps to promote organization, improve consistency among team members, and elevate spirits.
1. Going through your task list and making certain that all critical tasks were performed, including prescription refills and calling patients with abnormal lab reports 2. Making certain that everything is ready to go for the next day 3. Locking the drug room 4. Shutting down all lab instruments and x-ray equipment 5. Closing all examination room doors and turning off all of the lights in the clinical area. 6. Activating the security system before exiting the building
Reviewing and Maintaining Patient Charts The clinical medical assistant should make a copy of the schedule for the next day and tape a copy to her desk and a copy to the provider’s desk or other designated location. Charts are commonly pulled by the administrative staff the day before the appointment and taken back to the clinical area. This is usually performed sometime following lunch. When working with paper charts, do the following: 1. Make certain that the chart’s outside cover is in good condition. Repair any tears and re-adhere labels that may have loosened. (This may be performed by administrative staff members.)
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2. Inspect the inner contents of the chart to determine if the patient needs any new forms such as a new problem list or progress note. Make certain that all new forms have correct patient identification information. 3. Pull any recent lab or diagnostic test reports and attach them to the inside cover of the chart (Figure 2-11) so that the provider will have a chance to review the reports prior to meeting with the patient. Also consider attaching any forms that need to be signed by the patient, such as surgery consent forms or privacy statements. This will be a real timesaver when you are actively seeing patients. 4. Determine if the patient is behind schedule on any preventative health screenings or immunizations. If the patient is in need of a particular service, alert the provider by attaching a note to the front of the chart. Part of maintaining the medical record is making certain that the chart gets refiled. Whenever possible, charts should be filed within 24 hours of removal. The filing of charts is commonly performed by administrative staff members; however, always offer to help with filing if you have some extra time. This will improve your relations with administrative staff members. You never know when you may need a favor from them some day. Staff members will be much more willing to help you in your time of need if you are willing to help them in their time of need.
FIGURE 2-11 The results of all lab and diagnostic tests that have been completed since the last visit should be attached to the front inside cover of the chart, eliminating work for the provider.
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E M R A P P L I C AT I O N When using the EMR, check the patient’s electronic chart to determine if there are any outstanding lab or diagnostic reports. Check to see if the patient is up to date on all preventative health screenings, which are screenings that help to identify concerns before they become a problem such as colon exams, mammograms, cholesterol levels, and blood pressure screenings. Also check the patient’s immunization status. This can all be easily accomplished by clicking on the appropriate tabs in the EMR record. Some EMR programs are set up so that an alert is displayed when the patient is due for a specific screening exam or immunization. If there are any outstanding labs, a click on the icon will take you to the lab directory to download updates. If the outstanding results are not posted, call the lab or diagnostic center to determine when results will be available.
Creating and Implementing Daily Task Lists A task list refers to a list of jobs that need to be completed, usually within a certain time frame. A task list is meant to jog your memory so that you won’t forget to perform the task. Some tasks may be associated with the pending files, however other tasks will be related to operational functions, such as performing an inventory, placing an order, cleaning the autoclave, calling a drug representative, etc. It is important to update your task list on a daily basis. You will want to place the most important tasks with short time lines or critical information toward the top of the page and tasks that are not as important or have no time line association toward the bottom of the page. Highlight tasks as you complete them. Add to the task list when new tasks arise.
Working the Floor of a Medical Office Medical assistants who work in a clinical capacity usually spend the majority of their day “working the floor,” which means preparing patients, assisting the provider, and maintaining examination rooms. Time management is essential when working the floor because an inefficient medical assistant may cause the provider to run behind, which then impacts patient wait times and
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F IEL D S M A R T S
P A T I E N T P E R S P E CT IV E
One of the most common complaints voiced by those still using paper charts is the amount of time wasted in tracking charts. File charts within 24 hours of removal, whenever possible. Complete the user card in the out guide whenever you remove a chart. An out guide (Figure 2-12) is a temporary file that replaces a chart removed from the file. This assists other staff members who may need the chart for other purposes. If someone takes the chart from your possession, change the user information in the out guide. You do not want to be blamed for losing a chart that you gave to someone else.
I hate going to the physician’s office because the exam rooms are so cold. I think that you health care workers set the thermostat so that it is comfortable for you, not me. I understand that health care workers may be uncomfortable from all of the work they perform. At least you could offer me a blanket that will help me stay warm until the examination begins. That extra gesture shows me that you care about my comfort.
Preparing the Patient and Setting Up the Room for the Examination Once the patient enters the exam room, the medical assistant should perform the patient’s vital signs and obtain the patient’s chief complaint. The medical assistant will want to set the room and patient up according to the nature of the patient’s complaint. To learn more about preparing the room and patient for the exam, refer to Chapter 6.
Assisting the Provider during the Examination
how long other members of the health team have to stay to accommodate patients.
The medical assistant should determine whether the provider will need assistance during the examination or procedure. If there is a procedure that is to be performed such as a laceration repair, cyst removal, or pap and pelvic exam, the tray should be set up prior to the provider’s entrance. Medical assistants should be accessable for all procedures. Providers become very frustrated when they are ready to perform a procedure and the medical assistant is nowhere in sight.
Opening the Exam Room
Examination Follow-Up
When the medical assistant opens a room, she should turn on the lights and investigate to verify that the room has been properly cleaned. The medical assistant may also want to pull out the foot extension on the exam table so that patients can climb up on the exam table with ease. Checking the thermostat and making certain that the temperature is comfortable as well as checking that all drawers and cabinets are stocked (just in case someone used the supplies after the drawers were stocked the night before) are additional responsibilities of the medical assistant.
Often times, the provider will ask the medical assistant to follow up with the patient following the provider’s portion of the visit. The medical assistant may need to administer an injection, draw the patient’s blood, bandage the patient’s extremity, or perform an EKG. The provider may even request the medical assistant to set up an outside appointment for the patient. Any procedures performed must be documented. Once all procedures have been performed and documented, the medical assistant may have additional responsibilities in discharging the patient.
FIGURE 2-12 A chart that is removed should be replaced with an out guide so that all health care team members know where to find the chart should the need arise.
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Discharging the Patient In many offices the medical assistant will be responsible for discharging the patient. Different types of discharge responsibilities may include: 1. Gathering and dispensing drug samples and explaining how to properly take the samples 2. Writing or distributing prescriptions for the patient 3. Gathering educational forms and explaining any home care instructions 4. Setting up the patient’s next appointment (With electronic charting this can be performed directly from the examination room.) The medical assistant should always check to see if the patient has any questions regarding home care instructions and encourage the patient to call the office with any additional concerns or questions. Figure 2-13 shows a medical assistant giving the patient her prescriptions and educational materials at the end of the visit.
Duties to be Performed between Patients Once the patient is gone, the medical assistant will want to clear the monitor screen (when using electronic charting) so that the next patient cannot read information about the previous patient. She should remove paper from examination table and decontaminate the table and pillow (if applicable). The medical assistant
FIGURE 2-13 Medical assistants are usually responsible for giving the patient any discharge instructions from the provider.
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should throw away trash into the proper trash receptacle and place any nondisposable gowns or drapes into the laundry bin. Disinfecting all counter surfaces and replacing used supplies when necessary are additional tasks to perform when preparing the room. When using exam room indicators to distinguish the status of a patient room, the medical assistant should activate the indicator to alert health care workers that the room is ready for the next patient.
CLINICAL ASSISTING AND TIME MANAGEMENT ISSUES A very important rule to remember when working the floor is to stay at least one to two patients ahead of the provider at all times. There should never be any time when a provider is waiting on the medical assistant to room a patient. Table 2-2 is a floor management priority table.
PERFORMING ROUTINE MAINTENANCE ON CLINICAL EQUIPMENT Along with all the floor tasks, the clinical medical assistant may also be responsible for inventorying and ordering supplies. In addition, the medical assistant may be
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C R I T I C A L T H I N K I NG CHALLENGE You work for a provider who has three exam rooms. You are working with a patient in room 1 when the provider knocks on the door and tells you that she needs you to assist her with a Pap test on the patient in room 2. You still need to complete the workup on the patient in room 1 and room 3 is empty. List the order in which you will perform the tasks: ___ Finish working up the patient in room 1. ___ Put a patient in room 3. ___ Assist the provider in room 2. It is obvious that you are now behind; how might you get caught up?
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TABLE 2-2 Floor Management Priority Table FIRST PRIORITY
SECOND PRIORITY
THIRD PRIORITY
FOURTH PRIORITY
Assisting the provider with emergencies and procedures
Rooming patients
Performing procedures and dismissing patients
Working on pending files that have tasks
A seasoned medical assistant can usually anticipate when the patient is going to need a special procedure performed. The medical assistant can save a great deal of time by preparing items necessary for the procedure ahead of time. The medical assistant should not open any supplies until a direct order is given to perform the procedure. If the provider decides not to perform the procedure, all unopened supplies and equipment are placed back in their original locations.
When a room becomes vacant, the medical assistant should ready the room, retrieve the next patient from the reception room, document the patient’s chief complaint, and perform the patient’s vital signs. The medical assistant should always stay one to two rooms ahead of the provider. The provider should never have to wait on the medical assistant to room a patient. If an emergency occurs or the provider needs the medical assistant to assist with another procedure, another medical assistant may assist until the emergency or procedure is completed.
When a provider exits the patient’s room and orders a procedure, the medical assistant should immediately perform the procedure, unless there is a vacant room. In that case, the medical assistant should room the next patient so that she remains ahead of the provider. (If the procedure that the provider ordered is an emergency, then the procedure will take priority over rooming the next patient.)
Whenever time permits, the medical assistant should work on files that have tasks. Remember that many of the tasks will be in the form of returning phone calls that have come in throughout the day. It is important to prioritize individual tasks. Refer back to Table 2-1 for more information about task prioritizing.
responsible for maintaining equipment that is used in the clinical area. Examples of clinical equipment include: 1. 2. 3. 4. 5. 6. 7. 8.
Autoclave Lab equipment Pulmonary function unit EKG unit/Holter monitor Scales Automated external defibrillator Pulse oximeter Fire extinguishers
Most new equipment is purchased with a maintenance or service agreement. All such agreements should be placed in a special folder or notebook with the owner’s manual. The medical assistant should keep a separate journal that lists each piece of clinical equipment on its own page with the following information: the name of the item, manufacturer’s name, product ID number, name of supplier, and the telephone numbers for customer service and technical support.
Routine maintenance services should be scheduled following the manufacturer’s instructions. The medical assistant should check maintenance logs on a regular basis to establish if any equipment is due for maintenance and should regularly inspect clinical equipment for proper functioning. If any problems are noted, the medical assistant should contact the manufacturer’s technical support number for assistance. In the maintenance log, the nature of the problem, name of service representative, date of the call, and instructions given by the representative should be written down. When equipment is serviced, the technician conducting the service will usually attach a service tag to the piece of equipment to verify its maintenance. Surveyors for insurance companies and federal agencies will look for these service tags during inspections. Refer to Figure 2-14 for an example of a service tag. Refer to Procedure 2-1 for a complete procedure for performing routine maintenance on clinical equipment.
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SITE CHECK As an insurance site reviewer, I will be checking clinical equipment maintenance logs to make certain that the office is staying current in maintaining equipment. I will check lab equipment logs, fire extinguisher inspection logs, scale logs, autoclave spore check logs, and other equipment logs. These logs help to confirm that equipment is working properly and helps to ensure a safe environment. FIGURE 2-14 An example of a service tag
PROCEDURE 2-1 Performing Routine Maintenance on Clinical Equipment Objective: To determine which pieces of clinical equipment are ready for maintenance and to follow the proper criteria for setting up a maintenance appointment.
Equipment/Supplies: ❖ Maintenance log ❖ Writing utensils
❖ Clinical equipment
PROCEDURAL STEPS
RATIONALE
1. Read through the equipment maintenance journal and correctly identify which items are ready for routine maintenance.
It is important to determine when equipment is ready for routine maintenance. If you miss a routine maintenance appointment, equipment may be more prone to breaking down. Failure to have service when indicated in the service contract could also disrupt or nullify your service agreement with the manufacturer.
2. Call the supplier or manufacturer to set up a service call to perform the routine maintenance.
You will need to call the company that sold you the equipment or the manufacturer to obtain instructions for having the equipment serviced. Some manufacturers send service technicians to the office, while others will have the office send the equipment to them for servicing. When the latter occurs, the company should send the office a loaner model until the other equipment is serviced. continues
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continued
PROCEDURAL STEPS
RATIONALE
3. Make certain that the equipment is functioning properly once it is returned or before the technician leaves the premises.
It is important to ascertain that the equipment is functioning properly before the technician leaves. Sometimes defects will occur as a result of taking the instrument apart. It is better to identify this while the technician is still on the premises. If equipment was sent out for maintenance, check it as soon as it arrives. Additionally, you may only have a specified number of days to send the loaner equipment back once the original piece of equipment is sent back to the office. Failure to send the loaner equipment back in the time allotted could result in leasing charges from the manufacturer.
4. Record the maintenance into the maintenance log and place a maintenance sticker on the equipment if the technician or manufacturer fails to do so.
This documentation will assist you in knowing when it is time for your next maintenance check. It also provides a written document for insurance reviewers and other agencies that check equipment maintenance logs.
DOCUMENTATION EXAMPLE: Equipment maintenance log Name of equipment: Manufacturer: Model number: Original date of purchase: Name of rep: Technical repair phone # Customer service phone # Service agreement: FIRST SCHEDULED MAINTENANCE DUE BY
01-31-10
SECOND SCHEDULED MAINTENANCE DUE BY
01-31-11
EKG Machine Burdick 25987A 01-19-09 Mark Holland 800-888-1259 800-888-8965 3 Years
DATE OF FIRST MAINTENANCE CALL
MAINTENANCE PERFORMED IN-OFFICE OR OUT OF OFFICE
NAME OF PERSON PROVIDING THE MAINTENANCE
DUE DATE OF SECOND SERVICE CALL
01-17-10
In-Office
Peter Green
01-31-11
DATE OF SECOND MAINTENANCE CALL
MAINTENANCE PERFORMED IN-OFFICE OR OUT OF OFFICE
NAME OF PERSON PROVIDING THE MAINTENANCE
DUE DATE OF THIRD SERVICE CALL
ANY CONCERNS AND NAME OF EMPLOYEE OVERSEEING THE MAINTENANCE
“Instruct employees not to bend the wires on the lead cable.” S. Sullivan, CMA (AAMA) SPECIAL NOTES AND INITIALS OF STAFF MEMBER WHO SET UP THE APPOINTMENT
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Chapter Summary Good technical and personal skills are not the only skills that are necessary to perform well in the medical office. Excellent organization and time management skills are essential to perform efficiently both in the classroom and in the medical office. Start getting organized while you are still in school. Use desk calendars or planners to alert you when upcoming tests and competencies are scheduled. Review notes following each lecture and clean out book bags and notebooks on a daily basis to help keep you organized. Always think ahead when rooming patients. What trays or equipment might the patient need based on the patient’s complaint? How should the patient disrobe? What exams will you need to participate in? Work on callbacks or pending files throughout the day, and write daily task lists to help keep you organized and focused. Providers may reward medical assistants with wonderful organizational skills with extra earnings or even promotions.
FIELD APPLICATION CHALLENGE You are a relatively new medical assistant. You notice that both you and your provider appear to be the last ones to leave every day. You rarely get to take a lunch or any other breaks and it seems that your provider is always waiting on you to finish up with patients so that she can perform the examination. The provider has been very nice, but you sense that she is becoming more agitated because of continually running behind schedule.
1. What may be some contributing factors for always running behind? 2. How might you approach this with the provider? 3. Is there anyone else that might be able to assist you?
Chapter Assessment 1. The term provider usually refers to a: a. medical assistant. b. receptionist. c. physician, nurse practitioner, or physician’s assistant. d. LPN or LVN. 2. Instructions such as taking respirations on all patients with breathing disorders or putting anyone with chest pain into the trauma room would be an example of office: a. protocol. b. triage. c. assessment. d. pending task.
3. Lab results may be given to a patient’s spouse, only if: a. the patient gives verbal permission. b. the patient has indicated on the privacy statement that the spouse may receive result. c. the patient is unavailable. d. the spouse agrees to tell the patient. 4. A mammogram would be an example of a: a. yearly health requirement. b. preventative health maintenance procedure. c. physical maintenance. d. none of the above.
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5. When a medical assistant works in a clinical capacity, it is quite often referred to as: a. working the front. b. working the floor. c. treating patients. d. rooming patients. 6. You just worked up a patient in room 3. Dr. Jones comes out of room 2 and tells you that he needs an ECG performed on Mrs. Nasby in room 2. Dr. Jones now goes into room 3. Room 1 is open for a new patient. What should be your first priority? a. Rooming a patient for room 1 b. Run the ECG in room 2 c. Wait outside the door of room 3, just in case the provider needs you d. None of the above
Web Activities 1. Research an EMR vendor like Misys Healthcare Systems or Medical Office OnLine and review the various functions of their software. Write down 10 different ways that EMR can be a timesaver.
2. Type the following words in a search engine: “Time management tips for health care professionals.” Find an article that lists different ways that you can save time. Write a one page summary of your findings.
CONNECTION Using your StudyWARE CD-ROM: ❖ Complete the Concentration and Crossword activities for this chapter. ❖ Complete the Quiz for this chapter in Test Mode.
C H A P T E R
The Complete Medical Record and Electronic Charting Chapter Outline The Medical Record Important Uses of the Medical Record Medical Record Formats Source-Oriented Medical Record (SOMR) Problem-Oriented Medical Record (POMR) Combining Formats Contents of the Medical Record Administrative Information in a Medical Record Clinical Information in a Medical Record Creating and Maintaining the Medical Record Maintaining the Medical Record
Documenting in the Medical Record Electronic Medical Records (EMRs) Laws That Affect the Medical Record The Health Insurance Portability and Accountability Act of 1996 (HIPAA) Ownership, Retention, and Disposal of Medical Records Fees Associated with Copying of Medical Records Retention of Medical Records Disposal of Medical Records
3 Essential Terms assessment business associate agreement Certification Commission for Healthcare Information Technology (CCHIT) chronological order concierge medicine electronic health record (EHR) electronic medical record (EMR) flow sheet health information technology (HIT) Health Insurance Portability and Accountability Act of 1996 (HIPAA) individually identifiable health information (IIPI) notice of privacy practices continues
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KEY COMPETENCIES Creating and Maintaining the Electronic Medical Record
CAAHEP
ABHES
III.C.3.C.2.c
VI.A.1.a.3.b
Application of Electronic Technology
objective impressions personal health record (PHR) plan problem list problem-oriented medical record (POMR) progress note protected health information (PHI) shingling source-oriented medical record (SOMR) subjective impressions subjective, objective, assessment, plan (SOAP)
VI.A.1.a.2.n
Developmental Objectives After completing this chapter, you should be able to: 1. Correctly spell and define the essential terms. 2. List three different types of medical records and describe each one. 3. List important reasons for keeping neat, structured medical records. 4. List the two major types of formats that are used for documenting in the patient’s record. 5. Describe the POMR approach and list the pros and cons for using this system. 6. Describe each letter of the SOAP format and list appropriate information to include under each section. 7. List administrative and clinical components of the medical record. 8. List common functionalities of the EMR and the benefits of this system. 9. List who is responsible for certifying EMRs. 10. Define HIPAA and give examples of ways that the office can become HIPAA compliant. 11. Determine which sections of the medical record are owned by the health care provider and which sections belong to the patient. 12. Describe how long medical records have to be retained and how to properly dispose of them.
Introduction The medical record is the most important record kept in a medical office. A couple of different formats can be used to set up the medical record and to record entries within the patient’s chart. The medical record is divided into several sections, all of which contain different forms. Electronic medical records (EMRs) are becoming more popular in ambulatory medicine. The medical assistant must become familiar with the functions, benefits, and restrictions related to EMRs. There are laws that protect the private information contained in a patient’s chart and dictate how that information may be shared, with whom it may be shared, and how long a patient’s information should be stored once the relationship between the provider and patient is terminated. As a result of studying the information in this chapter, you will become familiar with various documenting formats used in medical establishments and gain an understanding of laws that are in place to protect patient information. EMRs and their functions are described in depth, providing you with essential information that will assist you when working in paperless offices.
THE COMPLETE MEDICAL RECORD AND ELECTR ONIC CHARTING
THE MEDICAL RECORD The medical record is an analysis of a patient’s health status. It contains a medical history, current findings, considerations, test results, and treatment information related to conditions or diseases that ail the patient. Notes in the medical record are usually entered by the physician and other members of the health care team, including the medical assistant. There are two major types of medical records that may be found in a medical practice: paper and paperless. Paper records are medical records that are stored in file folders. Paperless records are computerized records or records stored in digital format and are often referred to as electronic medical records (EMRs) or electronic health records (EHRs). Another type of medical record, the personal health record (PHR), is a copy of the patient’s own medical record that may be in paper or digital format. Many Web sites catering to the needs of patients include instructions for creating a PHR. Some medical offices create a PHR for patients as a perk for joining the practice. This is particularly common in concierge medicine (practices in which patients pay a fee for special services). Any time the patient is seen, the practice prints copies of the progress note and related lab or diagnostic results and gives them to the patient to place in the patient’s personal file. Information may be transmitted in digital format for those patients with electronic records. The patient takes the PHR to all medical appointment to help improve continuity between providers. The maintenance of the medical record is often assigned to administrative staff members; however, clinical staff members also have responsibilities in records maintenance. The clinical team is usually responsible for ensuring that all outstanding lab and x-ray results are entered into the record. They are also responsible for updating patient history and other data on a regular basis. Clinical staff members may have additional responsibilities such as removing data from the chart, copying the data, sending it to other health facilities, and returning any removed data to its original location. Any time the patient has an encounter with the medical assistant, whether it is over the phone, through e-mail, or in person, it must be documented in the patient’s record. With the latest rules of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and the proliferation of EMRs, it is more important than ever for clinical staff members to have a clear understanding of their roles in entering and retrieving
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data from patient files and the federal guidelines that dictate how patient information can be shared.
Important Uses of the Medical Record The most important purpose of a medical record is to provide the provider with precise health data to assist in formulating an accurate diagnosis, plan an appropriate treatment, and track a patient’s progress. The record also assists the provider in formulating disease prevention measures and overall health maintenance goals for the patient. Other functions of the medical record are: 1. To provide a means of communication: It is a communication tool that is used between providers to improve the continuity of care and contains instructions for other health care employees to perform various diagnostic procedures or to administer particular treatments (Figure 3-1). 2. To be used for financial purposes: Chart notes are used by a medical practice to determine the complexity of the office visit, the diagnostic procedures performed, and any treatment rendered. The insurance company may also use progress notes from the chart to establish medical necessity for specified diagnostic procedures or treatments. 3. To serve as a legal document: The chart is a legal document that can protect the provider against frivolous lawsuits. On the other hand, it can be used as an incriminating piece of evidence by a plaintiff to prove negligence in a medical malpractice suit.
FIGURE 3-1 The patient’s medical chart provides valuable information so that both providers and medical assistants know how to proceed with the patient.
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4. To be used as an educational tool: The chart may be used by medical students, residents, and health care providers as case studies. 5. To provide statistical data for research purposes: Patients may elect to participate in a clinical trial sponsored by a drug company or a company that manufactures medical devices. The medical record can be used to provide these companies with pertinent data regarding the overall effectiveness of their products and safety performance.
MEDICAL RECORDS FORMATS There are two different documentation formats that are used for medical records, the source-oriented medical record and the problem-oriented medical record.
Source-Oriented Medical Record (SOMR) The more traditional format used for recording data in the medical record is the source-oriented medical record (SOMR). Charts in which the SOMR format is used are divided into specific sections including: History and Physical, Progress Notes (notes that track the patient’s progress), Nursing/Medical Assisting Notes, Laboratory, and Diagnostic Testing. The “source” or individual providing the data enters the information within the appropriate section of the chart. There is no systematic cross-referencing of data from one section to the next. Progress notes are usually recorded in a narrative format, making it necessary to read the entire progress note before determining what is wrong with the patient. All reports and notes are kept in reverse chronological order, meaning the most recent note is on top.
Problem-Oriented Medical Record (POMR) The problem-oriented medical record (POMR), also known as the or POR, was developed by Lawrence L. Weed in the early 1970s. The POMR system incorporates structure and organization within the medical chart, stimulating better communication between those reading and those entering data within the chart. The POMR is developed using four categorizations or stages: 1. Develop a database: The database should include patient history, physical findings, and baseline readings for diagnostic and laboratory testing. 2. Assemble a detailed problem list: The problem list should record specific problems identified from the patient history form and should list new problems as they arise. Each problem is numbered and should include the name of the condition or
diagnosis. Each time the patient is seen for a particular problem, the progress note will reference the number listed on the problem list. If the problem is resolved, the date that the problem is resolved is entered onto the problem list. See Figure 3-2 for an example of a detailed problem list. 3. Formulate a plan of action for each problem: The plan for each problem may be found as a separate listing within the chart or may be included in the problem list. This section should include plans for testing, treatment, and education. 4. Provide ongoing progress notes for each problem on the problem list.
SOAP Notes The POMR system uses the subjective, objective, assessment, plan (SOAP) note format for each progress note. Table 3-1 lists each section of a SOAP note, the type of information included in each section, and states which personnel is responsible for entering information within each section. Figure 3-3 illustrates an example of a complete SOAP note. There are a number of advantages of using the POMR including: 1. It makes exploration of the chart much more efficient. 2. It decreases ambiguity of prior problems and treatment goals. 3. It encourages uniformity amongst those using the chart. 4. It simplifies record keeping.
Combining Formats Some offices may combine particular aspects of the SOMR and POMR formats. The record may be set up using the SOMR format, but the provider may use the SOAP approach when entering information on the progress note and may include an abbreviated problem list on the front inside cover of the chart. Regardless of which system is used, the medical assistant will need to learn how charts are set up within each office and the proper method for documenting information in the medical record.
CONTENTS OF THE MEDICAL RECORD Sections contained within the medical record will vary from one office to the next. Factors that influence which sections will be incorporated into the medical record include:
THE COMPLETE MEDICAL RECORD AND ELECTR ONIC CHARTING
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DOUGLASVILLE MEDICINE ASSOCIATES 5076 BRAND BLVD DOUGLASVILLE, NY 01234 (123) 456-7890 MASTER PROBLEM LIST Patient’s Name: Green, Kelly Date Problem/ Diagnosis/RO
Problem Number
02/14/XX
L. Otitis Media
1
07/15/XX
VTI
2
09/22/XX
Hypertension
3
DOB: 05-16-1955 Chart # 129876 Date of Plan Practitioner Resolve Abbreviations: Legg DP: None 2/26/XX RX: Amoxicillin, 500 mg CE: Ear Infection Fact Sheet Legg DP: Complete VA and C&S 7/25/XX RX: TMP-SMX CE: V T I Fact Sheet Legg DP: None Presently RX: Atenolol, 25 mg & Life style changes CE: BP Fact Sheet DP:
Recurrence Date
RX: CE: Legend: DP: RX: CE: FUP:
Diagnostic Plan Therapeutic Plan Client education Follow-Up Plan
FIGURE 3-2 A detailed problem list makes it easy for anyone using the chart to track patient problems and treatments without reading the entire chart.
TABLE 3-1 SOAP Notes Defined
❖ ❖ ❖ ❖
EXAMPLES OF WHAT IS INCLUDED IN EACH SECTION
PERSONNEL WHO TYPICALLY DOCUMENTS WITHIN EACH SECTION
SECTION NAME
DESCRIPTION
Subjective impressions (S)
Information provided by the patient
Patient’s chief complaint or reason for visit in the patient’s own words
Medical assistant, nurse
Objective impressions (O)
Information provided by the health care professional; includes a list of measurable reproducible data
Provider’s physical findings, patient’s vital signs, height and weight, laboratory results or other diagnostic data
Provider, nurse, medical assistant, other health care personnel who perform diagnostic testing
Assessment (A)
Interpretation of the subjective and objective findings
Diagnosis
Provider
Plan (P)
Provider’s plan for diagnosing and treating the patient
Names of lab and diagnostic tests to be performed, forms of treatment, and educational plans
Provider
Physician’s personal preference Type of practice Cost of supplies Regulatory requirements
Many of the forms found in a medical chart can be purchased through a supplier and can be printed with the name, address, and phone number of the practice
located at the top of each form. Generally, charts are divided into two major sections: ❖ Administrative information ❖ Clinical information The chart’s front cover should include the patient’s name or identification number, and color-coded stickers
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OUTLINE FORMAT PROGRESS NOTES Patient Name
Prob. No. or Letter
5
S
O
Yvette Garcia A
P Page
DATE
Subjective Objective Assess
Plans
9/6/01
Patient complains of two days of severe high epigastric pain and burning, radiating through the back. Pain accentuated after eating.
4
On examination there is extreme guarding and tenderness, high epigastric region no rebound. Bowel sounds normal. BP 110/70 R/O gastric ulcer, pylorospasm To have upper gastrointestinal series. Start on Ametidine 300 mg daily Eliminate coffee, alcohol & aspirin Return two days.
FIGURE 3-3 An example of a POMR progress note page (Courtesy of Bibbero Systems, Inc., Petaluma, CA, 800-242-2376, www .bibbero.com.)
Start each Progress Note (Subjective, Objective, form. Write through the intervening columns to the
that identify the last year the patient was seen. It may also include stickers that alert staff members when a patient is allergic to a particular drug.
Administrative Information in a Medical Record Administrative information is information that is used most often by administrative staff members. Occasionally, members of the clinical team may also need to refer to these sections. Administrative sections within the medical record may include the following:
Assessment and Plans) at the appropriate right margin of the page.
shaded column to create an outline
❖ Demographic: A patient registration or acquaintance form that includes personal information about the patient including address, phone number, insurance information, etc. ❖ Insurance: Copy of the insurance card, referrals, and precertification requests ❖ Correspondence: Letters from insurance companies, attorneys, etc. ❖ Legal: Copy of the patient’s privacy statement, living will, and advance directives
THE COMPLETE MEDICAL RECORD AND ELECTR ONIC CHARTING
Information within each section is usually placed in reverse chronological order, or the most recent date on top.
Clinical Information in a Medical Record The majority of information found in a patient’s chart is considered to be clinical data. Clinical data is information that providers use to help diagnose, prescribe, and treat patients. Clinical information should also be placed in reverse chronological order. The following is a description of each section of clinical data found in a patient’s chart.
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Medical History The medical history form is normally completed during the patient’s initial visit and updated during subsequent visits. This form may be completed by the patient, provider, or medical assistant. It is a tool used for assessment purposes. It gives the provider subjective information about the patient and patient’s family and provides a database that can be used to build upon. See Chapter 5 for more information regarding the medical history section.
Some EMR software programs have a medical history component that can be completed rather easily. The user simply identifies each disease or condition that is applicable by clicking on the “Yes” response, and clicking on the “No” response for conditions that are nonapplicable. A new template of questions may appear, allowing the user to expand on “Yes” responses. The majority of software programs allow users an opportunity to personalize the medical history to coincide with their particular specialty.
Patients may also participate in completing the electronic history by using a kiosk in the examination room or by completing the requested health information online, prior to the first appointment. If there is no medical history component built within the EMR software, the medical assistant may need to scan the history form within the patient’s electronic file. Figure 3-4 illustrates an example of a computerized history form.
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E M R A P P L I C AT I O N
FIGURE 3-4 An example of a computerized patient history (SynapseEHR 1.0 screen shots courtesy of E.S. Butler.)
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Physical Exam The physical examination is a key component of the diagnostic approach for each patient and provides an overview of the patient’s general condition. The physical exam involves a head-to-toe evaluation of the patient, organized by body system. It is an important tool for discovering any new problems and monitoring previously identified problems. A physical exam is usually performed during the patient’s initial office visit and every one to three years thereafter. The frequency of physical exams depends on the following: ❖ The patient’s overall health status and age ❖ Insurance protocol ❖ The type of physical (annual, sports, work, or presurgical)
The patient’s insurance company or payer usually sets specific guidelines for the time span between physicals. When a patient requests a physical, the office staff should check to determine that the timing or reason for the physical falls within the payer’s parameters. If the parameters do not meet insurance guidelines, the patient should be warned by a member of the health care team beforehand of the exact financial responsibility. It is also customary for patients to have a physical prior to a surgical procedure. The patient may be examined by the surgeon or the primary care physician. A copy of the history form should be faxed or e-mailed to the hospital where the surgery is to be performed. Specialty forms may be used for physical exams or the physical exam findings may be documented on a standard progress note.
E M R A P P L I C AT I O N Entering information within the progress note is quite simple. The user may use standardized templates for entering patient data, or may copy and paste information from prior visits and make the appropriate adjustments. The user can integrate information from other sections of the chart directly onto the progress note—such as lab findings, history information, and the
FIGURE 3-5 An example of a computerized progress note (SynapseEHR 1.0 screen shots courtesy of E.S. Butler.)
patient’s medication history—by simply clicking on the appropriate tabs. EMR reduces documentation time significantly and can save the practice thousands of dollars in the long run. Figure 3-5 illustrates a progress note in which information from other parts of the chart have been integrated within the progress note.
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THE COMPLETE MEDICAL RECORD AND ELECTR ONIC CHARTING
Progress notes are the heart of the patient record. They serve as a chronological listing of the patient’s overall health status. Data pertaining to the findings from the visit are entered on a progress note, usually in the SOAP format. The progress note form may also be used for recording telephone encounters, procedures, treatments, and other interactions that take place with the patient. The header on the progress note should
include the patient’s name, birth date, and any allergy alerts. Before entering any information on the progress note, ensure that you have the correct chart by asking the patient to verify his full name and birth date.
Medication Records Some offices have patient charts with a separate section for medication entries; other offices have team members document medication treatments directly onto
E M R A P P L I C AT I O N Many EMR programs have a prescription component that can be accessed by clicking on the prescription tab. The prescription software can store thousands of common drug names with their usual dosages. The user brings up the patient’s electronic chart, clicks on the prescription tab, and selects the name and dosage of the ordered drug (Figure 3-6). The number of refills to be given is selected, as well as the
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name of the physician ordering the prescription. There is normally an option for printing, faxing, or e-mailing the order. The software may have individual patient logs for immunizations, narcotics, and other drugs administered within the office. Universal or global logs may also be stored within the EMR to track drugs administered to all patients for reporting purposes.
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Progress Notes
❖
FIGURE 3-6 An example of an electronic prescription screen. With just a few clicks, an entire prescription can be created. (SynapseEHR 1.0 screen shots courtesy of E.S. Butler.)
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the progress note. Prescribed drugs may be logged in a separate section from those administered or dispensed. The medical assistant should avoid using abbreviations when documenting medications or use only standard abbreviations that are not listed on the “Do Not Use” abbreviation list in Appendix B of this text. Medical assistants should always check the individual policies of the office in which they work.
Phone Reports Any time a patient calls to change an appointment, give a progress report, obtain test results, or request
a prescription refill, the call should be recorded either on the progress note or on a special phone form and placed within a special section of the chart. Medical assistants should check the policy of the office in which they work for specific details. Education Sessions At times, it is necessary to give the patient home care instructions including postoperative, test preparation, disease management, and medication instructions. The patient should be given both verbal and written instructions. The session should be documented on a progress note and within the appropriate logs.
E M R A P P L I C AT I O N Many EMRs have special phone templates that make it easy to record information. The user clicks on the telephone icon or tab and completes the requested information by clicking on a few more tabs (Figure 3-7). A message is sent
FIGURE 3-7 Telephone messages are easily created in an EMR. (SynapseEHR 1.0 screen shots courtesy of E.S. Butler.)
to the “Task” box of the provider instructing the provider to pull up the telephone entry. The provider may then send a message back to the medical assistant with instructions to perform a specific action.
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THE COMPLETE MEDICAL RECORD AND ELECTR ONIC CHARTING
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E M R A P P L I C AT I O N Educational sessions may be recorded directly into the progress note or within a special log when using electronic records. Some software programs have educational data stored directly within the electronic software. The software allows the user to print a copy of the educational data for the patient at the point of care, or to send the material to the patient by faxing or e-mailing the information.
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Laboratory Documents All lab forms should be placed in reverse chronological order and placed in the lab section of the chart. Some offices use the shingling method for filing lab reports when reports are not on a standard size piece of paper. Lab reports are attached to a special shingling form that coincides with the lab reporting form. The forms may be color coded to match one another. Only like or similar reporting forms are placed on the same shingling form (for example, all urinalysis reports, all CBC reports, etc.). Adhesive strips on the shingling form allow lab reports to adhere to the front of the form. The first lab report on each form is placed so that it
Many programs feature an orders management section that allows users to order lab testing. Once a test is ordered, it is stored in the memory of the database. Designated personnel may access the lab information by downloading it from the appropriate Web site and transferring it into the patient’s electronic record. An electronic message is sent to the “Task” box of the requesting provider. Abnormal labs are flagged for immediate review. Once reports are reviewed, a message is sent to the medical assistant’s “Task” box with instructions for handling
each lab. The medical assistant will perform the task and make an entry within the progress note stating that the task has been completed. There are many customizable options for displaying lab reports depending on the software used including displaying by test category, by individual test (Figure 3-8), alphabetically, and even in a graphing format. Medication levels that affect various lab results may also be displayed in a cell beside the corresponding lab result, making decision making about medication changes much easier.
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E M R A P P L I C AT I O N
FIGURE 3-8 In an EMR, lab results are readily displayed and easily tracked. (SynapseEHR 1.0 screen shots courtesy of E.S. Butler.)
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is even with the bottom edge of the shingling form. Each subsequent report is shingled upward about a half an inch above the previous lab report (see Figure 3-9 for an example of the shingling method). Lab tests are used to aid providers in formulating a diagnosis, monitoring specific diseases or conditions, and monitoring medication levels. Common laboratory reports include hematology, urinalysis, microbiology, cytology, and chemistry reports. When using paper charts, the medical assistant must attach a copy of the report to the front of the chart and place it on the provider’s
FIGURE 3-9 Reports are
desk for review. Any abnormal results should be given directly to the provider or placed at the top of the chart pile for immediate review.
Diagnostic Reports Copies of the patient’s nonlab-related procedures should be placed in the diagnostic reports section of the chart. Procedures such as imaging reports, EKGs, and heart catheterizations are examples of diagnostic procedures. When using paper charts, the medical assistant must attach a copy of the report to the front of the chart and
LABORATORY REPORTS
filed in a shingle fashion with the most recent lab report always on the top. (Used with permission. InHealth Record Systems Inc., 5076 Winters Chapel Road, Atlanta, GA, 30360, 800-477-7374; www.inhealthrecords.com.)
PLACE TOP OF REPORT #13 HERE
PLACE TOP OF REPORT #12 HERE
PLACE TOP OF REPORT #11 HERE
PLACE TOP OF REPORT #10 HERE
PLACE TOP OF REPORT #9 HERE
PLACE TOP OF REPORT #8 HERE
PLACE TOP OF REPORT #7 HERE
PLACE TOP OF REPORT #6 HERE
PLACE TOP OF REPORT #5 HERE
PLACE TOP OF REPORT #4 HERE
PLACE TOP OF REPORT #3 HERE
PLACE TOP OF REPORT #2 HERE
PLACE TOP OF REPORT #1 HERE
INSTRUCTIONS: TO ATTACH REPORT, REMOVE PROTECTIVE TAPE BACKING, ALIGN REPORT AND PRESS DOWN FIRMLY, REPEAT PROCEDURE FOR SUBSEQUENT REPORTS.
RECORD SYSTEMS
FORM F260
5076 Winters Chapel Road • Atlanta, Georgia 30360 1-800-477-7374 • 1-770-396-4994
LABORATORY REPORTS
THE COMPLETE MEDICAL RECORD AND ELECTR ONIC CHARTING
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CR ITI C A L TH I N K I N G C H AL LEN G E The provider wants you to show the patient his blood sugar results for the last year and track what medications appear to be most responsive to lowering his blood glucose. 1. What type of lab display would be best for this scenario?
either place it on the provider’s desk or hand it directly to the provider when results are abnormal.
Consultation Reports The days of one provider treating all that ails the patient are gone. Practitioners frequently send patients to specialists for further examination. The specialist will send thank-you letters to the referring provider and will provide a report of particular findings and plans for the referral patient. When using paper charts, the medical assistant must attach a copy of the consultation report to the front of the chart before giving it to the provider.
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reports from nursing homes, providers of therapeutic services, and hospitals. Nursing Home Reports Nursing home documents are frequently faxed or e-mailed from nursing homes and extended care facilities. This is especially true in family practice and geriatric offices. It is very important that these documents be given to the provider prior to being filed in the patient’s chart. If the office is using paper charts, the correspondence is attached to the front of the chart prior to giving it to the physician. With EMR, the information is either downloaded or scanned into the patient’s EMR. Therapeutic Reports Therapeutic reports may also be faxed or sent electronically from various facilities and may include reports from medical personnel, such as a physical or occupational therapist, who provide rehabilitative or therapeutic treatments for the patient. Once again, these reports should be read by the physician before they are filed into the patient’s chart. With EMR, the information is either downloaded or scanned into the patient’s EMR.
Other reports that may be placed under the Consultation, Miscellaneous, or Correspondence tabs include
Hospital Reports Any time a patient visits the hospital, a report of that visit will be sent to the patient’s primary care provider (PCP) and other pertinent health care providers. Hospital reports may include history and physical reports, operative reports, emergency room reports, and discharge summaries. Most patients will be instructed to follow up with their PCP once they leave the hospital.
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Nursing Home Reports, Therapeutic Service Reports, and Hospital Reports
EM R AP P L I C A T I ON
EMR APPLICATION
The procedure for inserting diagnostic reports will vary depending on the EMR software and the electronic capabilities of the diagnostic testing center. If there is a direct link between the two, the reports are handled similarly to the way that lab tests are handled; otherwise the results are scanned directly within the EMR. In-house computerized diagnostic equipment may link directly to the EMR software. Once the test is performed, the medical assistant is able upload the results electronically into the patient’s electronic record.
Many medical offices are electronically linked to hospitals with which they are affiliated. This type of affiliation allows the provider and other health care personnel who have special pass codes to explore and download information from the hospital’s various department Web sites. The provider can track diagnostic and laboratory tests as well as the status of patients who have been hospitalized. Hospitals may opt to fax reports to the provider. If so, the information will either have to be scanned into the chart or manually entered using a special template.
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E M R A P P L I C AT I O N Electronic exchange of information makes it much easier for providers to communicate with one another. When using EMR, referral letters, thank-you letters, and consultation reports can be sent electronically between the primary care provider and specialist. A clinical summary (Figure 3-10) that displays the patient’s problem
list, medication list, allergy list, and family history is usually sent to the consultant at the time the referral is made. Once reports are received, they are downloaded and saved in the consultation or correspondence section of the chart. An electronic task is sent to the provider referring them to the patient’s chart and report.
DOUGLASVILLE MEDICINE ASSOCIATES 5076 BRAND BLVD DOUGLASVILLE, NY 01234 (123) 456-7890 CLINICAL SUMMARY Page 1, printed on 10/30/2008
date of birth: 2/18/1934
White, Blanche Current Problem List 1. Hypertension 2. Osteoporosis 3. Depression
FIGURE 3-10 This clinical summary form displays key information about the patient that will assist other health care providers caring for the patient.
Medicine List 1. Cardizem 2. Fosamax 3. Paxil
dose 60 70 20
Drug Allergies 1. Peanuts 2. Codeine
comments
unit mg mg mg
begin 3/12/2008 3/12/2008 3/12/2008
instructions Take 1 capsule daily Take 1 tablet per week Take 1 tablet each morning
date
Old Problem List comments Upper Respiratory Infection
from: 10/10/2007
to: 10/20/2007
Old Medicine List & Prescription Refills Amoxicillin 500 mg
Rx’ed 10/10/2007
d/c’ed 10/20/2007
Family History Heart disease
comments
Special Notes Patient prefers to be addressed by her first name.
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THE COMPLETE MEDICAL RECORD AND ELECTR ONIC CHARTING
Flow Sheets Flow sheets are logs found in the patient’s chart that assist the provider in monitoring specific repetitive information, at one glance. These may also be referred to as “health care screenings.” Types of flow sheets include PT/INR results, glucose or HgbA1c results, and blood pressure readings. A variety of patients may have flow sheets including those who are diabetic, those on
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Coumadin therapy, and hypertensive patients. Any time a patient has a test or procedure performed that is listed on the flow sheet, it should be documented onto the flow sheet as well as the lab form. Flow sheets may also be used to track routine health screenings such as mammograms, pap smears, and PSA levels. Figure 3-11 shows an example of a flow sheet.
CREATING AND MAINTAINING THE MEDICAL RECORD
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Steps for creating the medical record will vary depending on whether the office is using a paper or paperless system. The chart is usually created by administrative
EM R AP P L I C A T I ON EMR flow sheets work well not only because of their ability to group results but also because they can automatically alert the provider when a patient is past due for a particular health screening. The user just clicks on the designated button and a message comes up that informs the user of any screenings the patient is behind on. Some EMR software incorporates features that will automatically enter lab results directly into the patient’s electronic flow sheet. Every time that lab result is filed in the patient’s lab file, the test name, result, and date will also be added to the electronic flow sheet.
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SITE CHECK As a chart auditor for the insurance company, I check to see if the patient is up to date on all preventative maintenance testing, examinations, and immunizations such as mammograms, pap tests, and infant vaccinations. The practice should be able to verify that the patient was offered the testing, even if the patient failed to comply.
FIGURE 3-11 Because lab reports are placed in chronological order, lab results should be entered in the paper chart starting with the last line and working upward. All results outside the normal range should be written in red or another color that stands out.
DOUGLASVILLE MEDICINE ASSOCIATES 5076 BRAND BLVD DOUGLASVILLE, NY 01234 (123) 456-7890 HgbA1c FLOW SHEET Patient’s Name: Cindy McDonald
Patient’s Birth Date: 03/17/1967
Patient’s ID # 45687
Provider’s Name: Dr. Laura Samoni
Date of Test
Result
Current Med
Current Dosage
Recommended Change in Dose (If any)
10/10/XX
6.8
03/16/XX
8.2
09/19/XX
7.0
03/20/XX
6.6
08/29/XX
6.8
Avandia Triglide Avandia Triglide Avandia Triglide Avandia Triglide Avandia Triglide
8 mg 160 mg 4 mg 160 mg 4 mg 160 mg 4 mg 160 mg 4 mg 160 mg
None None 8 mg None None None None None None None
Provider Making the Change
Dr. Samoni
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staff members, but maintained by both clinical and administrative staff members. The clinical staff may need to file items within the patient’s chart, insert new forms, and make minor repairs to the chart.
Maintaining the Medical Record Once a patient record is created it must be properly maintained. The chart is regularly inspected and any physical tears mended. Loose labels should be firmly reattached. Misplaced reports should be reviewed to determine if they have been released for filing and then placed in the appropriate section of the record. When forms such as progress notes and flow sheets are over 75% complete, new forms should be placed nearby so that they are easily assessable when needed. Part of maintaining a chart is making certain that all information is updated. The record should be checked regularly to make certain that all labs are up to date and that the patient is current on health maintenance screenings. Once the provider and medical assistant are finished using the chart, it should be released for filing.
Documenting in the Medical Record Documenting within the patient’s record is a common task performed by medical assistants. As stated earlier in the chapter, all patient encounters are to be documented within the patient’s chart. Documentation should be accurate and thorough yet concise. Medical assisting students should practice all types of documentation throughout their training period (see Chapter 4 for documentation guidelines).
Electronic Medical Records (EMRs) An EMR is a patient’s medical record in digital format. It provides users with secure real-time information about the patient at the point of care and from remote locations. The term electronic health record (EHR) is often used interchangeably with EMR; however, there is a formal distinction between the two among medical record organizations and those involved in health informatics. C. Peter Waegemann, CEO of the Medical Records Institute, differentiates the two by describing EMR as “an electronic record with full interoperability within an enterprise (hospital, clinic, practice)” and EHR as “a generic term for all electronic patient care systems.” To get a sense of the interoperability of EHR consider a patient entering an emergency room (ER) complaining of chest pain. The patient had a physical the previous week with his PCP. Because the patient had some prior chest pain symptoms earlier in the week,
the PCP ordered a stress test, heart ultrasound, and multiple lab tests, all of which were performed at an outside facility. Figure 3-12 illustrates what occurs within an electronic health network. The connection is initiated when the PCP sends an electronic task to the medical assistant asking her to order the tests for the patient (a). The medical assistant sends electronic orders to the facility where the tests are to be performed (b). The testing facility receives the orders and sends the results back electronically to the PCP (c), where they are reviewed and downloaded into the patient’s EMR (d). The ER physician calls the PCP for some insight on the patient’s condition, and the PCP sends the findings from the physical, all diagnostic and lab reports, and a copy of the patient’s clinical summary back to the ER physician (e). In a matter of minutes, the ER physician has vital information that is necessary for determining necessary testing, making a diagnosis, and treating the patient (f).
Features of EMRs The electronic record has many features designed to improve patient care and staff efficiency. The type of software that a medical practice selects will depend on
(a)
(b)
(f)
(c)
(e)
as
death.
(d)
FIGURE 3-12 A computer network provides health care workers with the necessary information with just a click of a button.
THE COMPLETE MEDICAL RECORD AND ELECTR ONIC CHARTING
many factors including the type of practice, the number of practitioners within the practice, the goals of the practice, and the individual preferences of the clinicians and staff. An overview of various EMR functions includes: ❖ Creates customized progress notes and builds notes efficiently through standardized templates and copy/paste features ❖ Enables the provider and staff members to e-mail or fax progress notes, prescriptions, and orders directly from the point of care ❖ Allows team members to schedule appointments from the point of care ❖ Automatically files and displays lab results in a variety of different formats ❖ Graphs lab values, pediatric growth patterns, and vital signs ❖ Displays several parts of the chart at one time ❖ Allows multiple users access to different parts of the chart at the same time ❖ Provides electronic tasking features to help keep staff members organized and greatly improves time management ❖ Provides full remote access of patient records for those authorized to view them ❖ Interfaces with the clinic’s practice manager program, making billing more efficient ❖ Provides reporting and benchmarking capabilities that allow users to compare patient outcomes or to track other statistical data EMRs have enhanced the organization and structure of the traditional paper medical record. As more facilities move toward EMRs, the more elaborate these programs will become, providing more options than what are currently available.
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Creating and Maintaining an EMR The medical assistant may have responsibilities in both creating and maintaining an EMR. The amount of responsibility will be determined by office protocol. In general, the medical assistant may be responsible for any of the following when dealing with EMRs: creating the patient’s electronic chart, updating basic demographic information, completing an electronic history, updating legal information, documenting subjective findings within progress notes, documenting vital signs and other procedures into the appropriate sections of the chart, creating electronic lab requisitions and prescriptions based on the physician’s order, creating letters from templates stored within the EMR, downloading lab and diagnostic testing results from outside facilities, documenting within specialized patient logs (such as immunization, educational, etc), and scanning paper items into an electronic format. Attention to detail is important when performing these tasks. The medical record—whether in paper or electronic format—is a legal document that can be used in a court of law. See Procedure 3-1 on how to create and maintain an electronic medical record.
Amending Information in an EMR When documenting information within an EMR, the user may need to omit or add items. There normally is no problem making changes during the initial entry, but once the entry is submitted, the user may only have a limited amount of time before that information is stored and any further changes to the original entry are prevented. To correct an error, the user must access the note that needs to be amended and select the appropriate amendment option. This may vary depending on the specific EMR software. Any changes that are made to the progress note following submission are tracked and stored for future reference.
Pitfalls of EMRs EMRs have many benefits, but there are also a few pitfalls such as: ❖ ❖ ❖ ❖
Cost of the software Training time and costs to the facility Problems that occur when the system goes down Increased risk of unauthorized persons obtaining identifiable health information about the patient
Remember that all records are confidential, so a patient’s file should never be accessed unless it is absolutely necessary.
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TOOL BOX
P A T I E N T P E R S P E CT IV E I have mixed feelings about electronic medical records. I understand their value, but I’m worried about the different people that can access my personal information. I hope that the staff will demonstrate integrity and respect my right to confidentiality when working in my file.
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Certification of EMRs In September of 2005, the U.S. Department of Health and Human Services (HHS) awarded a contract to the Certification Commission for Healthcare Information Technology (CCHIT) to develop and evaluate the certification criteria and inspection process for EHRs. In order for a health information technology (HIT) vendor—a company that develops software for health care organizations—to get their product certified, the software must meet the basic criteria of the CCHIT for functionality, interoperability, and security. This certification reassures consumers that the product complies with all governmental requirements. CCHIT announced its first ambulatory certified products in 2006 and posts an updated list of software routinely. The CCHIT certified its first inpatient EHR products in 2007. For a listing of certified products, visit the CCHIT Web site (www.cchit.org).
The Push for EMR In 2004, President Bush put forth an executive order pushing for most Americans to have electronic health records by 2014. The Centers for Medicare and Medicaid Services (CMS) is developing a variety of incentives for health care providers to adopt EMR, such as increases in Medicare and Medicaid reimbursements to those practices using EMR and supplying qualifying offices with federal grants to purchase EMR software.
LAWS THAT AFFECT THE MEDICAL RECORD Many laws affect medical records. It is important to become familiar with both state and federal guidelines to ensure compliance and avoid noncompliance penalties related to the violation of such laws. Governmental agencies, such as the CMS and the HHS, continuously make changes that may impact the way health care workers handle patient information. One such law dealing with patient information comes from the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) Currently, HIPAA has seven subdivisions, each with its own title. This section will address Title II of this bill, which has the greatest impact on medical offices. The CMS is responsible for implementing various provisions of HIPAA. Title II of HIPAA encourages the use of electronic data interchange in health care. One of the most impor-
tant aspects of this subdivision is the privacy rule. Title II requires that the medical office and all affiliates of the medical office adopt measures to protect the security and privacy of patient health data. To assure the accountability of those who have access to protected health information (PHI) or individually identifiable health information (IIHI), Congress requires the imposition of civil and criminal penalties for any person or entity that uses PHI improperly.
Patient Protections According to the HHS, “The privacy regulations ensure a national floor of privacy protections for patients by limiting the ways that health plans, pharmacies, hospitals, and other covered entities can use patients’ personal medical information or PHI. The regulations protect medical records and other individually identifiable health information, whether it is on paper, in computers or communicated orally.” Key provisions of the new standards include: 1. Access to Medical Records: Patients should be able to obtain copies of their medical records and request corrections if they identify errors or mistakes. Access should take place within 30 days of the request. 2. Notice of Privacy Practices: Patients should receive a notice of how their personal medical information may be used. This will be expanded upon below. 3. Limits on Use of Personal Medical Information: PHI may not be used for outside business purposes unrelated to health. 4. Prohibition on Marketing: The provisions set restrictions and limits on the use of patient information for marketing purposes without the written consent of the patient. 5. Stronger State Laws: The new federal privacy standards do not affect state laws that provide additional privacy protections for patients. When a state law requires a certain disclosure, such as reporting an infectious disease, the federal regulations do not preempt the state law. 6. Confidential Communications: All information that is contained in the patient’s chart is considered confidential. Health care workers should never release information without a written authorization. Patients may also request the office to call them at their place of business instead of their home. The office should comply with the patient’s wishes, when the request is reasonably able to be accommodated.
THE COMPLETE MEDICAL RECORD AND ELECTR ONIC CHARTING
7. Complaints: Consumers may file a formal complaint regarding the privacy practices of a covered health plan.
Notice of Privacy Practices One of the changes listed above included providing patients with a notice of privacy practices. This notice should disclose the different ways in which the patient’s PHI may be used. See Figure 3-13 for an example of a notice of privacy practices form. Examples of information for uses and disclosures of PHI that may be found in the practice’s privacy statement include:
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1. Sending information to other health care providers, such as laboratories, physicians, and pharmacies, for consultation or treatment purposes 2. Sending information to insurance companies or clearing houses for payment purposes 3. Using PHI for “health care operations” purposes, which may include the ability of the practice to evaluate the quality of care patients receive, information sent to attorneys or accountants to conduct cost-management, and business planning activities for the practice 4. Using PHI for communication purposes with the patient’s family including relaying appointments,
Notice of Privacy Practices This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully. Our health care providers work together to provide the best care to their patients. As allowed by law and only if needed, health information is shared to provide the best treatment, arrange for payment, and improve how we provide care in the future. The purpose of this notice is to tell you how we share your information and how you can find out more about our information sharing practices. You will be asked to acknowledge receipt of this Notice of Privacy Practices. I.
We Have a Legal Duty to Protect Your Health Information: By law, we must keep your health information private and tell you that we are doing so. This includes your past, present, and future health information (your condition, care provided to you, or payment). We must follow the terms of this notice. If they change, we will change the notice so you will be aware of the changes. You can get a copy of any revised notice by contacting Douglasville Medicine Associates, 5076 Brand Blvd., Suite 401, Douglasville, NY 01234.
II.
We May Use and Disclose (Share) Your Health Information: 1.
Treatment/Care—Your health information may be used by staff members or disclosed to other health care professionals for the purpose of evaluating your health, diagnosing medical conditions, and providing treatment. For example, results of laboratory tests and procedures will be available in your medical record to all health professionals who may provide treatment or who may be consulted by staff members.
2.
Payment—Your health information may be used to seek payment from your health plan, from other sources of coverage such as an automobile insurer, or from credit card companies that you may use to pay for services. For example, your health plan may request and receive information on dates of service, the services provided, and the medical condition being treated.
3.
Health care operations—Your health information may be used asnecessary to support the day-to-day activities and management of Douglasville Medicine Associates. For example, information on the services you received may be used to support budgeting and financial reporting, and activities to evaluate and promote quality.
4.
Contact—Your health information may be used by us to contact you about your visit. Also, we may use your health information to contact you about treatment alternatives or health related benefits and services that may be of interest to you. Any information about your visit may not be left on an answering machine, voice mail, or with an individual other than yourself who may answer the phone.
5.
Law enforcement—Your health information may be disclosed to law enforcement agencies, without your permission as needed: To reports wounds, injuries, and crimes To support government audits and inspections To facilitate law-enforcement investigations If we suspect child abuse or neglect If we believe you are a victim of abuse, neglect, or domestic violence Under court order To comply with government mandated reporting.
5.
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Public health reporting—Your health information may be disclosed to public health agencies as required by law. For example, reporting injuries, births, deaths and we are required to report certain communicable diseases to the state’s public health department. For deceased patients, by law and only if needed, we must share your health information with cornoners and funeral directors.
FIGURE 3-13 An example of the first page of a HIPAA privacy statement
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messages to have the patient call the office, or to disclose health information to family members in the event of an emergency 5. Using PHI in the event of an ownership change 6. Using PHI when notifying public health authorities for reporting communicable diseases and abuse situations 7. Using PHI in lawsuits and similar proceedings The form should also list rights of the patient regarding their health information and should have a section stating with whom information can be shared when the patient is unavailable.
Security Measures for HIPAA Compliance Because this chapter focuses heavily on EMR, it is important to also address security measures for EMR. These measures include: 1. Reviewing the office’s business operations to identify which HIPAA electronic transactions apply 2. Assigning a HIPAA coordinator/officer who will be responsible for making the organization HIPAA compliant 3. Identifying partners that have access to PHI such as health plans, clearinghouses, software vendors, and billing companies. Partners should be queried to ensure their HIPAA compliance. All business partners should sign a business associate agreement that describes exactly how protected information is to be handled 4. Implementing testing measures to ensure business partners are HIPAA compliant 5. Using a third-party certification service or tool that can make certain that the practice is HIPAA compliant Internal security measures may include the following: 1. Backing up computers at the end of each day and storing the backup in a secure place outside the office, such as a bank deposit box 2. Using encrypted passwords 3. Creating limited accessibility accounts for employees 4. Changing pass codes on a regular basis 5. Providing HIPAA training for all staff members Table 3-2 lists good privacy practices and practices to avoid pertaining to HIPAA.
Penalties for Violation of HIPAA Laws Penalties for violating HIPAA laws include fines that range from $100 to $250,000 and prison time that ranges from 1 to 10 years depending on the number
TOOL BOX
C R I T I C A L T H I N K I NG CHALLENGE Mr. Walker calls the office and states that he heard a message on his answering machine that his wife needed to call the office. He states that his wife is out of town and asks you to give the information to him. 1. Are you allowed to release the information to the husband? 2. Where in the chart can you find out if you can release the information? 3. If after checking the documentation in the chart you find that you can release the information to the husband, how much information should you release?
and type of violations. See a breakdown of penalties in Table 3-3. Confidentiality issues are serious. Unauthorized access to medical information can affect the patient’s employment status, family life, and personal relationships. Accessing patient records without cause may result in termination from employment. Many health care facilities have software that can track where employees have accessed patient records and identify who is adding or changing information in the medical record. This is referred to as an “audit trail” and is a vital component toward maintaining patient confidentiality. Because of the sensitivity and confidentiality issues related to patient information, it is crucial for all providers and staff to avoid situations in which personal integrity can be challenged.
OWNERSHIP, RETENTION, AND DISPOSAL OF MEDICAL RECORDS In general, medical records are the property of the practice or treating physician or hospital. The practice or physician owns the physical part of the record, but the patient is the owner of the information stored within the chart. Patients are entitled access to their medical records and may request copies of it. If a patient requests a copy, the patient must sign a release. Only copies—and not the originals—of the record should be sent to the patient. When working with electronic records, the medical assistant should make a copy of
THE COMPLETE MEDICAL RECORD AND ELECTR ONIC CHARTING
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TABLE 3-2 Good Privacy Practices and Practices to Avoid GOOD PRIVACY PRACTICES
PRACTICES TO AVOID
Only access a patient’s file when it is absolutely necessary.
Never access a patient’s file because a friend or relative wants to find out information about the patient.
When sending information about a patient to a covered entity, only send the minimal amount of information that is necessary to handle the request.
Never send more information than what is necessary.
Turn computer monitors away from patients, or keep them out of the patient’s sight.
Do not allow computer monitors to display patient files in areas where the patients are in viewing range. (If using electronic records in the patient rooms, be certain all information from the previous patient has been cleared before bringing in a new patient.)
Use sign-in sheets that require minimal information to acknowledge the patient’s arrival and the time of arrival or have patients sign in via computer.
Sign-in sheets should not ask patient to list any changes since the last visit, such as changes in insurance or other demographic information.
Talk to the patient in private regarding billing or health-related information.
Do not discuss private information about or with a patient in an area where others can hear what you are discussing.
Allow the patient access to the patient’s medical record and the ability to review and request changes within 30 days of request.
Do not forbid the patient access to the patient’s medical record. Remember the patient is the owner of the information stored in the chart.
Only discuss parts of the patient’s record or health status with those individuals who have the authority to receive the information.
Do not discuss parts of the patient’s record with anyone other than the patient or those listed in the privacy statement. Do not discuss PHI with members of the health care team, unless it is absolutely necessary in order for them to carry out the duties of their job.
In the event of an emergency, provide the minimal amount of information that is necessary to handle that emergency.
Do not communicate more information than is absolutely necessary to handle an emergency. Keep voices low to ensure privacy.
Respect the patient’s right to privacy away from the office.
Do not tell friends or family members that a particular patient was in for an appointment. Even if you do not disclose the reason for the visit, it is a violation of HIPAA rules.
the record on a CD or forward the record electronically to the next provider.
Fees Associated with Copying of Medical Records “Reasonable fees” for copying a patient’s medical records will usually be dictated by state statutes. In most cases, the practice can charge fees for retrieving, copying, and mailing the medical record. Check each state’s policies for specific details.
Retention of Medical Records Federal and state guidelines for retention of medical records will vary depending upon the type of record.
In general, adult records should be retained for 7 to 10 years and records of minors should be retained several years past the age of majority. Check the state and federal laws that apply to the practice. It is prudent to follow the guidelines of the agencies that have the most stringent standards. If a practice decides to cease operations or physicians within the practice plan to change locations, the practice should notify patients to determine how their records should be handled. Each patient should be consulted to determine if records should be transferred to another location of the patient’s choice, or if they should be moved with the transferring physician. If neither occurs, the patient should be alerted to where
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TABLE 3-3 HIPAA Penalties TYPE OF PENALTY
DESCRIPTION OF PENALTY
Civil
Violations of simplification requirements
$100 per violation, up to $25,000 per year
Criminal
Knowingly obtains or discloses IIHI
Up to $50,000
1 year
Criminal
Offenses committed under false pretenses
$100,000
5 years
Criminal
Offenses committed with the intent to sell, transfer, or use IIHI for commercial gain, personal gain, or malicious harm
$250,000
10 years
the records are being stored in case the information is needed by the patient at a later date.
Disposal of Medical Records Occasionally, the medical record itself or parts of the medical record need to be discarded. Privacy laws state that PHI disposal must occur by shredding the documents; therefore, a shredder should always be used when disposing of information from a patient’s medi-
FINE
PRISON TIME
cal record. Many businesses hire a shredding company to perform their shredding. In that case, the medical facility must select a reliable vendor that has thorough knowledge of HIPAA guidelines and should have the company sign a business associate agreement that states that the records are not to be used for any other purpose but for shredding and that the company is to provide a certificate of destruction once the task has been performed.
PROCEDURE 3-1 Create and Maintain the EMR Using SynapseEHR 1.0 Software Objective: To create an EMR and perform various tasks within the record.
Equipment/Supplies: ❖ Computer ❖ Printer
❖ SynapseEHR 1.0 software CD-ROM located in the back of the workbook
PROCEDURAL STEPS
RATIONALE
1. Create the chart by clicking on the “New Patients” icon and completing all of the screens within the patient information section.
In SynapseEHR 1.0, this step is what actually creates the chart and assigns a number that will link the patient to other sections within the EMR.
2. Perform an electronic history on the patient by clicking on the “Patient History” tab and completing the requested information.
The history provides important information to help diagnose current diseases and conditions and assists in predicting future problems.
THE COMPLETE MEDICAL RECORD AND ELECTR ONIC CHARTING
PROCEDURAL STEPS
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RATIONALE
3. Update information within the legal screen by clicking on the “Legal” icon and completing the requested information.
The legal screen in SynapseEHR 1.0 allows the user to enter facts regarding discussions that occur with the patient in regards to medical/legal documents such as DNR orders, living will, durable power of attorney, etc.
4. Create a progress note on the patient by clicking on the “Chart Notes” icon and clicking on the “New Office Visit” tab.
The progress note details the reason for the visit. The progress note in SynapseEHR 1.0 contains four separate tabs for each part of a SOAP note.
5. Enter the date and time into the appropriate fields.
The date and time are important reference items that are used when referring to the note at a later date.
6. Click on the “Subjective” tab and complete the appropriate information. Save and update the information to the progress note.
The subjective information in SynapseEHR 1.0 refers to the patient’s chief complaint and is normally recorded by the medical assistant. In SynapseEHR 1.0, saving the information does not transfer it to the progress note. The medical assistant must click on “Update Progress Notes” to send the information to the progress note.
7. Click on the “Objective” tab and enter the patient’s vital signs. Save and update the information to the progress note.
Objective information is information provided by medical staff members. The only objective findings that the medical assistant will record in SynapseEHR 1.0 are the vital signs. Once these findings are documented, they too will need to be sent to the progress note.
8. Create the requested lab requisitions by clicking on the “Labs” icon and following the prompts on the screen.
Electronic lab orders can save everyone a great deal of time and can alert the lab that the specimens for testing are on their way.
9. Create the requested prescriptions by clicking on the “Rx” icon and following the prompts.
Prescriptions that are electronic reduce reading errors that occur from poorly written prescriptions. SynapseEHR 1.0 allows users to print the prescriptions, but many programs allow users to fax and e-mail prescriptions directly to the pharmacy.
10. Document requested information within the appropriate logs by clicking on the “Logs” icon in the main menu for global logs, and clicking on the “Immunization” icon within the patient information menu. Enter requested information into each field and save.
Logs within the patient’s personal EMR track immunizations and other medications that are administered to the patient. Global logs track medications administered and prescribed on all patients in the practice and important lab information.
11. Create any letters ordered by the provider by clicking on the “Patient Template” icon within the patient information menu and selecting the appropriate template. Complete the requested information and print a copy of the forms for the patient.
Creating letters and forms within the patient’s personal EMR tailors the letter to the individual patient and saves a great deal of time for the medical assistant.
12. Pull up the requested educational forms by clicking on the “Patient Education Forms” icon and selecting the appropriate material.
Patient education is one of the most important elements during the patient’s visit. Having these materials stored in the EMR allow users to print, e-mail, or fax the forms to the patient. continues
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continued
PROCEDURAL STEPS
RATIONALE
13. Go back into the progress note and complete the visit by clicking on the “Complete Visit” icon. Exit out of the software.
Once the medical assistant and provider are done with the patient, the note needs to be properly closed so that no one else can go in and make alterations.
13. Go back into SynapseEHR 1.0 and bring up the same patient’s EMR.
This illustrates the medical assistant’s ability to go back into the chart and enter results.
14. Click on the “Lab Orders” icon and click on the “Lab History” icon. Click on the “Update Lab Results” icon and complete requested information.
Whenever a test is performed, it must be documented. The test results may not be completed by the time that the visit is concluded, making it necessary to go back into the chart at a later time to document the findings.
15. Properly exit the program by clicking on the “Main Screen” icon and clicking on “Quit.”
Chapter Summary The medical record is an important tool in maintaining patient health. Understanding the sections of the medical record and knowing what information pertains to each section will save time for everyone who uses the chart. An organized medical record promotes good communications from one staff member to the next and better care for the patient. Electronic medical records (EMRs) are quickly replacing paper records. The advantages of using EMRs include better communication, organization, electronic networking with outside facilities, and increased efficiency. Eventually EMR use will be a requirement for offices that submit federal claims in order to receive the highest compensation possible. Federal and state laws dictate how the medical community uses PHI, what rights patients have to medical information, security measures designed to protect patient information, and the length of time records should be kept. Becoming familiar with standard procedures for documenting within a medical record and comprehending laws that protect information stored within the record will result in better care for the patient and a secure environment for protected health information.
FIELD APPLICATION CHALLENGE As a medical assisting student, you perform your externship in an office that uses EMR. You were able to see the wonderful advantages of EMR and are hopeful that you will get a position in an office that uses EMR. Unfortunately, the office that hires you still uses paper records. The physician has stated several times that he is hesitant to use EMR because of the software cost. Write a proposal to the physician stating why the office should go from paper records to EMR. To
help you prepare, complete the following: 1. On a separate sheet of paper, list at least 10 functions of EMR. 2. List at least five advantages for using EMR. 3. Using an Internet search engine, look up three different EMR software vendors and price their software.
THE COMPLETE MEDICAL RECORD AND ELECTR ONIC CHARTING
Chapter Assessment 1. Important uses of the medical record include all of the following except: a. means of communication. b. statistical data. c. payment data. d. information to pharmaceutical companies. 2. Which format has no systematic cross-referencing of information? a. POMR b. Organizational c. SOAP d. SOMR 3. In the POMR format, the category that includes patient history, physician findings, and baseline results is the: a. problem list. b. database. c. plan. d. progress notes. 4. Which organization has been approved to certify products from HIT vendors? a. CCHIT b. CMS c. OSHA d. HHS 5. Internal security measures to protect PHI include: a. using encrypted passwords. b. limiting account accessibility. c. changing pass codes on a regular basis. d. all of the above. 6. Which of the following would be considered a subjective finding? a. Vital signs b. Physical exam findings c. Diagnostic test results d. Patient’s chief complaint 7. Nonlaboratory test results should be filed in which section of the medical record? a. Demographic section b. Diagnostic reports c. Progress notes d. Lab reports 8. HIPAA helps protect: a. PHI. b. IHI. c. PMI. d. PPE.
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9. In order to give personal health information to a relative, the patient must: a. state the name of the individual on the privacy statement. b. have written consent from the patient to share information. c. both a and b. d. none of the above.
Web Activities 1. In reference to the last question in the Field Application Challenge, go to www.cchit.org and list which vendors have certified products. 2. Check your State Medical Board’s Web site for information on the length of time that medical records must be kept.
CONNECTION Using your StudyWARE CD-ROM: ❖ Complete the Crossword Puzzle activity for this chapter. ❖ Complete the Quiz for this chapter in Test Mode.
THE DVD LINK On your StudyWARE CD-ROM, go to the DVD Challenge for this chapter. View the DVD clip and respond to the following questions: 1. How did Irv try to prevent the patient from overhearing another patient’s information? 2. List other ways that Irv and the physician could have preserved the patient’s anonymity. 3. Do you agree with the way that the medical assistant addresses the physician? How would you address the physician?
C H A P T E R
Fundamentals of Documentation Chapter Outline Guidelines for Documenting in the Patient’s Chart Documenting for Legal Success General Guidelines for Documenting in the Patient’s File The Use of Medical Abbreviations in Chart Entries Documenting Chief Complaints and Progress Notes Documenting Laboratory Procedures Documenting In-Office Procedures Documenting Medications
Documenting Prescriptions Documenting Patient Education Sessions Documenting Telephone Calls Documenting Referrals Documenting Precertifications Documenting Outside Procedures Documenting Hospital Admissions Making Corrections or Addendums to Chart Notes Documenting and Sending Faxes Writing and Sending E-Mails
4 Essential Terms addendum chief complaint “Do Not Use” abbreviations list Institute for Safe Medication Practices (ISMP) Joint Commission (JC) participating provider precertification referral
F U N D A M E N TA L S OF D O C U M E N TAT IO N
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Developmental Objectives After completing this chapter, you should be able to: 1. Correctly spell and define the essential terms. 2. Provide documentation practices that will aid in the physician’s defense should the record be subpoenaed in a court of law. 3. List 11 “Documentation Dos” and four “Documentation Don’ts” when documenting in the medical record. 4. Recognize and memorize abbreviations that are routinely used in medical documentation. Recognize and avoid using abbreviations that appear on the Joint Commission’s “Do Not Use” abbreviations list. 5. List items that should be recorded when documenting laboratory procedures, in-office procedures, medication procedures, prescription orders, patient education sessions, patient telephone calls, referrals, precertifications, outside procedures, and hospitalizations. 6. List the steps that should be taken when making a correction or an addendum to both a paper and paperless record. 7. Describe why information on the fax cover sheet is so important. 8. Describe proper etiquette guidelines that should be adhered to when sending professional e-mails.
Introduction A large percentage of the communication between health care professionals today is through written or typed communications. A provider discovers the reason for the patient’s office visit by reading the documentation recorded in the patient’s chief complaint. If a patient calls the office requesting a prescription refill, it is more than likely communicated to the provider through a written message or through documentation contained within the patient’s chart. Other types of professional communication also transpire through written or typed messages and may include faxes and e-mails. Supervisors and employees interact regularly through corporate e-mail. Parts of the medical record are often sent to hospitals and other providers’ offices by fax. How well medical assistants communicate can set the stage for how far they progress in the industry. What type of impression will supervisors acquire if they continually find spelling errors within the medical assistant’s documentation or are unable to decipher what the medical assistant has written due to poor handwriting or incomplete documentation? Moreover, poor documentation within the patient’s chart may cause the office to become more vulnerable when lawsuits arise. Employers just cannot take those kinds of risks. Consider also the business side of poorly written communications. Faxes and e-mails containing errors may cause patients to question the quality of their medical care and personnel from other health care facilities to lose respect for the practice that submitted the correspondence.
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GUIDELINES FOR DOCUMENTING IN THE PATIENT’S CHART
This chapter specifically addresses general documentation guidelines, both within and outside the chart.
The medical record conveys a story about the patient. It houses the patient’s history, progress notes, and lab data so that anyone caring for the patient will have a foundation to build upon. It also assists administrative staff members in knowing what services need to be billed and to which parties. In professional liability cases, the medical record may become evidence aiding judges and jury members in determining the guilt or innocence of those involved. Documentation within the patient’s chart is the essential tool that providers and health care workers use to communicate with one another regarding the patient’s overall health status. There are several state and federal guidelines in place that protect documentation stored within the chart. There are also federal guidelines in place designed to help reduce the risk of injury to the patient due to undecipherable documentation. Medical assistants must become familiar with these guidelines to avoid infractions to the office and harm to the patient. Chapter 3 introduced laws that govern the medical record and listed components of the medical record.
Chart notes within the medical record can be a dynamic defense against frivolous lawsuits or can be the trigger for a disastrous defeat (Figure 4-1). Accurate and thorough documentation is essential when documenting the medical record. The chart is a legal document that is used in all professional liability cases and much of the jury members’ opinions will be formed by what is written or typed in the chart. Poor documentation may equate to poor medical care in the eyes of jurors. Procrastination is a pitfall to avoid when referring to the task of documentation. The medical assistant should document findings either during or immediately following each patient encounter to promote comprehensive and accurate documentation. Documenting procedures hours after they occur may cause the medical assistant to forget important facts related to the patient encounter or medical procedures. It could even cause the medical assistant to forget the encounter or procedure altogether. Refer to Figure 4-2 for a common adage that is used in many medical programs and in medical facilities all over the country.
Documenting for Legal Success
FIGURE 4-1 Notice that the practice’s chance of winning a medical professional liability case is much greater when records are thorough and documentation is complete.
Poor or Little Documentation
Plaintiff Information
A Win for the Plaintiff
Thorough and Complete Documentation
Plaintiff Information
A Win for the Practice
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The following is a list of “Documentation Dos”:
“IF YOU DIDN’T DOCUMENT IT, YOU DIDN’T DO IT!”
FIGURE 4-2 The judge’s comments emphasize the importance of documentation in the patient’s chart.
Lack of documentation has been the deciding factor in many professional liability cases that were lost. Any time the medical assistant has an encounter with the patient, even if it the encounter appears to be minor or trivial, it should be documented in the medical record. Objectivity is also important when documenting for legal success. The medical assistant should avoid comments that could appear subjective or trite. Statements such as, “It doesn’t appear that the patient changed her bandage since the last appointment,” could appear insensitive and judgmental in the eyes of a juror. A better way to address this type of scenario would be to state that, “The patient’s dressing was soiled with dirt and dried blood and was torn in several places.” This type of statement presents straight facts without appearing subjective and may indicate contributory negligence on the part of the patient in the event that a lawsuit does transpire.
General Guidelines for Documenting in the Patient’s File Now that you understand some of the legalities associated with medical documentation, the following section will address basic foundational guidelines that must be adhered to when documenting in the patient’s chart.
1. Do Make Certain That You Use the Correct Chart: Some patients may have the same name. It is imperative that in addition to checking the patient’s name that you also check for another identifier such as the patient’s date of birth or the last four digits of the patient’s social security number. This will help to ensure that you have the correct chart and the correct patient. Using the wrong chart could be disastrous to the patient who receives the wrong treatment because the provider has incorrect information. Billing patients for office visits that never occurred will certainly make the office appear disorganized to those patients affected as well as to the insurance company that was billed incorrectly. Repairing wrong entries can also be a nightmare. 2. Do Document All Patient Encounters: Document each office visit, all procedures, each telephone call, and all appointment-related changes such as broken, cancelled, or rescheduled appointments. Multiple appointment changes incurred by the patient may help to demonstrate negligence on the part of the patient should a lawsuit arise. 3. Do Chart Thoroughly: As stated previously, professional liability cases are frequently lost due to incomplete or missing documentation. Thorough documentation aids in the communication process among all those using the chart, which equates to better care for the patient.
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FI E L D S M A R T S The latest “National Patient Safety Goals” are a set of required standards for all institutions accredited by the Joint Commission (JC). One of the goals mandates the use of two patient identifiers when identifying patients for medication administration or lab testing. First, you should compare the name on the chart with the patient. In addition, use at least one other identifier such as the patient’s birthdate or the last four digits of the patient’s social security number to ascertain that you have the correct chart. Following these guidelines will help prevent needless errors that could harm the patient and lead the practice into litigation.
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4. Do Document Accurately: Make certain that each entry is accurate. Inaccurate documentation may generate many problems from inaccurate diagnosis to inaccurate treatment and incorrect billing. 5. Do Use Correct Spelling: Proper spelling is imperative when documenting in the patient’s chart. Spelling errors in a chart entry makes the medical assistant who made the entry appear deficient and also creates an overall negative impression of the office to outsiders reading the chart notes. Refer to Appendix C for a list of commonly misspelled everyday words and Appendix D for a list of commonly misspelled medical words. 6. Do Document the Date and Time of Each Entry: Documenting the date and time can be very important when referring to times of medication administration or when a procedure or treatment is administered. It can also be very important for worker’s compensation and personal injury cases. 7. Do Chart Legibly: If the documentation cannot be read, it cannot be distinguished. 8. Do Identify Your Chart Entries by Documenting an Approved Closing Signature: Many offices ask employees to sign their entries by documenting their first and last name followed by credential. This will help to alleviate any confusion as to who signed the entry should the entry be challenged at a later date. 9. Do Document Informed Consent or Refusal to Follow Directions: Informed consent is a legal doctrine that requires practitioners to provide patients with a complete set of facts prior to surgical procedures or medical experiments. Information must include the nature of the treatment, possible benefits, possible risks, and possible alternative treatments. The provider is usually responsible for presenting this information and will ask the patient to sign a consent form at the conclusion of the explanation and should also document the encounter on the progress note. The medical assistant may be responsible for preparing the form prior to the explanation of the procedure or treatment. The encounter is usually documented on the progress note as well. Refer to Figure 4-3 for a copy of a procedure consent form. When a patient refuses treatment or to follow office instructions such as waiting the allotted time following an allergy injection, it should be documented in the chart with the patient’s signature beside it. Some offices have the patient sign a “Refusal to Follow Medical Advice” form (Figure 4-4). 10. Do Only Use Standard Abbreviations: Because abbreviations can easily be misinterpreted, many
medical facilities are reducing the number of abbreviations that they allow workers to use or are eliminating them altogether. 11. Do Document on Every Line: Leave no open lines that can be altered at a different time and draw a line to the end of the margin when the last line extends only partially across the page. Just as there is a list of “Documentation Dos,” there is also a list of “Documentation Don’ts”: 1. Don’t Procrastinate: Never rely on your memory. Information is much clearer during or immediately following a patient encounter. 2. Don’t Diagnose: List the symptoms only. If the patient states that she feels she may have a urinary tract infection or migraine, use the patient’s exact wording placed in quotation marks. 3. Don’t Document for Someone Else and Don’t Allow Others to Document for You: Allowing others to document for you may set you up for an array of problems. The other person may intentionally or inadvertently leave out important facts. If you administer an injection, you should follow the injection from preparation to documentation. There should be no breaks in the chain. When you document the injection, you are taking ownership of the injection from start to finish. 4. Don’t Alter Records: Altering records may appear that you have something to hide. Never scribble over or use correction fluid to correct an error in a record, and never rewrite a progress note. Lawyers who suspect wrongdoing may hire handwriting specialists to review patient records they feel may have been tampered with or recreated. If you need to make a correction, follow the directions under the section entitled, “Making Corrections or Addendums to Chart Notes” found toward the end of this chapter.
The Use of Medical Abbreviations in Chart Entries To assist with time management and reduce the length of chart entries, standard medical abbreviations may be used when entering information within the medical record. The use of medical abbreviations, particularly medication abbreviations and symbols, has been heavily scrutinized over the past few years due to the number of errors related to their use. The Joint Commission (JC), a national organization that focuses on improving the quality and safety of services provided by health care organizations, recently published a “Do Not Use” abbreviations list of medica-
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CONSENT TO OPERATION, ADMINISTRATION OF ANESTHETICS AND RENDERING OF OTHER MEDICAL SERVICES 1.
I hereby authorize and direct Dr.
, my physician, and
whomever he/she designates as his/her assistants (associates and/or resident physicians), to perform upon (state name of patient or myself) the following procedures:
If any unforeseen condition arises in the course of this operation for the physician’s judgment to perform procedures in addition to or different from those now contemplated, I further request and authorize him/her to do whatever he/she deems advisable and necessary in these circumstances. Such additional services may include, but are not limited to, the administration and maintenance of anesthesia and the performance of services involving pathology and radiology. 2.
The following information has been explained to me to the degree that I wish to have it discussed: • The nature and character of the proposed treatment or procedure; • The anticipated results; • Possible recognized alternative methods of treatment, including non-treatment; • Recognized serious possible risks, complications, and anticipated benefits involved in proposed and alternative treatments, including non-treatment. My questions have been answered to my satisfaction. I acknowledge that no guarantee, warrantee, or assurance has been made as to the results or cure that may be obtained.
3.
Federal Regulations (21 CFR Part 821) require manufacturers to track certain medical devices, and assist the U.S. Food and Drug Administration (FDA) with notification to individuals in the event that a certain medical device presents serious health risks. I authorize and agree to the release of my contact information to the manufacturer: for this tracking purpose only. I understand that the manufacturer may notify me, if necessary, of important safety information about my medical device, and may release my information to the FDA if ordered to do so. I understand that this consent is valid for the life of the medical device.
Any sections below that do not apply to the proposed treatment may be crossed out. The patient must initial any section crossed out. 4.
I consent to the administration of blood and blood products if deemed medically necessary. I understand that all blood and blood products involve the risk of allergic reaction, fever, hives, and in rare circumstances infectious diseases such as hepatitis and HIV/AIDS. I understand that precautions are taken by the blood bank in screening donors and in matching blood for transfusion to minimize those risks.
5.
I hereby consent to the disposal or use for research purposes any tissues, parts, or products of conception, which may be removed.
6.
I authorize and agree to the presence of observers during my surgical procedure. These observers may include persons other than the medical staff that are considered appropriate by my health care provider during my care and treatment. The purpose of these individuals observing would be for instruction and medical study.
I certify that I have read this form and understand its contents.
PATIENT NAME & ID #
Signature of Patient or Legally Responsible Party Relationship to patient, if not signed by patient Signature of Witness Printed Name of Witness Date MRD: HOSP1 DISTRIBUTION:
Time 1-WHITE – CHART
tion abbreviations as part of their 2006 National Patient Safety Goals. The “Do Not Use” abbreviations list is a list of abbreviations that are commonly misinterpreted and should no longer be used when documenting medication orders within the patient’s medical record, or when writing medication orders that are to be sent to other health care facilities. The Institute for Safe Medication Practices (ISMP), which is a governmental organization that specifically seeks ways to promote medication safety,
2-CANARY – PATIENT COPY
a.m. / p.m.
FIGURE 4-3 An example of a patient consent form
has also compiled a list referred to as the “List of ErrorProne Abbreviations, Symbols, and Dose Designations.” This list includes all of the JC’s “Do Not Use” abbreviations and several other dangerous abbreviations. Refer to Appendix A for a list of approved medical abbreviations and symbols that may be used in chart entries and Appendix B for the ISMP “List of ErrorProne Abbreviations, Symbols, and Dose Designations” that should not be used when recording entries within the chart.
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DOUGLASVILLE MEDICINE ASSOCIATES 5076 BRAND BLVD DOUGLASVILLE, NY 01234 (123) 456-7890 REFUSAL OF MEDICAL ADVICE FORM I do hereby refuse the following medical test, treatment, procedure, or advice as recommended by Dr. Karl Valentine at Douglasville Medicine Associates.
Proposed Advice: Waiting 30 Minutes Following an Injection. I have been fully instructed regarding the possible consequences of not following the advice listed above. Complications may include but are not limited to: Developing an allergic reaction to the medication and going tnto anaphylaxis which could lead to death.
I am fully aware of my condition and understand the possible consequences that exist by refusing to follow medical advice.
I certify that I have read this form and completely understand its contents. Name of Patient or Person Acting on Behalf of the Patient: Debbie Johnson Signature of Patient or Person Acting on Behalf of the Patient:
Relationship to Patient: Self Signature of Witness:
Today’s Date: 05/19/10
************************************************************************ Refusal to Sign: Patient or representative of patient has recieved a full explanation in regards to the possible consequences in not following the advice listed above but refuses to sign the form. Signature of Witness:
Today’s Date:
FIGURE 4-4 An example of a refusal to follow medical advice form
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CR ITI C A L TH I N K I N G C H AL LEN G E
SITE CHECK
You notice that some fellow employees are still using abbreviations listed on the “Do Not Use” abbreviations list when documenting entries within patient records. 1. What should be your course of action, if any?
As a chart reviewer, I will check to see if health care workers making entries in the charts are using abbreviations that appear on the “Do Not Use” abbreviations list. Continued use of these abbreviations may result in infractions against the practice.
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Documenting Chief Complaints and Progress Notes The chief complaint is the reason that the patient is being seen. It is a listing of the patient’s symptoms and should be written using the patient’s own words whenever possible. The chief complaint should be short, concise, and flow well. A progress note is a follow-up note from a previous visit. This information elaborates on the patient’s progress between visits. Because this information is related to in-office screenings, refer to Chapter 6 for a complete listing of information that should be included when documenting a chief complaint or a progress note and samples of each.
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C R I T I C A L T H I N K I NG CHALLENGE While performing phlebotomy, you miss the patient’s vein on the first two attempts. You finally obtain a sample on the third attempt. You don’t want the physician to know that you missed the patient’s vein two separate times. 1. Regardless, why is it important for you to document failed attempts? 2. Write a sample documentation of how you would document this type of encounter.
Documenting Laboratory Procedures Often times, the medical assistant will be asked to obtain patient specimens and send them to an inhouse laboratory or an outside reference facility; however, the medical assistant may also be responsible for performing the testing. The medical assistant must be thorough in the documentation by listing the type of specimen collected (blood, urine, stool, sputum, etc.), from where it was collected (antecubital vein in left arm, right hand, throat, etc.), and whether or not the test was performed in the office or sent to an outside laboratory. If testing was performed by the medical assistant, the entry should include the results as well.
Items Listed When Documenting Laboratory Procedures Table 4-1 lists items that should be recorded when documenting laboratory procedures. The medical assistant should document the procedure in both the patient’s chart and onto a lab log. The purpose of the log is to track outstanding labs.
Documenting In-Office Procedures Medical assistants will routinely perform other types of diagnostic tests and procedures in addition to laboratory tests. These procedures may include vital signs, EKGs, pulmonary function tests, and results for pulse oximetry testing. The medical assistant should document the name of the procedure, where it was performed (if applicable), the results (if applicable), and who ordered the testing.
Items Listed When Documenting In-Office Procedures Table 4-2 lists specific items that should be listed when documenting procedures that are performed in the office.
Documenting Medications The medical assistant is often responsible for administering and dispensing medications and calling in prescriptions (Figure 4-5). Anytime the medical assistant performs a medication procedure or calls in a prescription, it must be documented in the patient’s chart. Chapters 32, 33, and 34 address procedures for these tasks. This chapter will concentrate on the documentation of these procedures.
FIGURE 4-5 The medical assistant must make certain that she has the correct information when talking to the pharmacist and have the pharmacist repeat back the information to ascertain that the information is correct.
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TABLE 4-1 Items Listed When Documenting Lab Procedures INFORMATION TO BE DOCUMENTED
DESCRIPTION OR FACTS
1. The date and the time of collection or testing
This is very important because specimens must be tested within the proper time frame to guarantee that the results are accurate.
2. What type of specimen was collected and from what location when applicable
Type of specimen: stool, sputum, blood, urine. Location from where the specimen was collected: throat, wound, L. hand, etc. The method used to collect the blood, such as vacuum, syringe, or butterfly method. Location of blood draw, such as antecubital vein in L. arm, right hand, etc. Color and number of tubes drawn, for example, 2 lavender top tubes and 1 red top tube.
If procedure is a blood draw, list the following information:
3. The name(s) of the test(s) to be performed
Make certain that you list all the tests to be performed. Providers often order multiple tests, for example, CBC, Complete UA, Metabolic Panel, etc.
4. The name of provider ordering the testing
You must show an order for any test that is performed.
5. The results of the tests when applicable
If the testing was performed in-house, document the results in both the patient’s chart and the lab log.
6. Where specimens were sent when applicable
This is important because it illustrates that the specimen was sent out and to which lab it was sent should problems occur.
7. Any reference numbers assigned to the test such as an acquisition number
Many labs will assign a number to the specimen for tracking purposes.
8. Any complications that occurred during or following the procedure
Examples of complications that may occur include: fainting, vein collapsed, patient experienced prolonged bleeding following the blood draw, etc. This information can assist those who take care of the patient during future visits to take steps to prevent such complications.
9. Closing signature
First and last name, followed by your credential; for example, Megan Speck, CMA (AAMA)
10. Record information in lab log.
The lab log helps to keep track of who had lab procedures and where they were sent. This also assists with tracking.
DOCUMENTATION EXAMPLE #1: DOCUMENTING LAB PROCEDURES
05-16-XX 1115
DOCUMENTATION EXAMPLE #2: DOCUMENTING LAB PROCEDURES
Blood draw (Syringe Method), L. arm (antecubital vein) for a CBC, PT, PTT, and INR per Dr. Chow. 1 lavender and 1 light blue top tube sent to Quest Labs. Acquisition #2357A. Pt. tolerated procedure well. No complications. Sam Brown, CMA (AAMA)
10-12-XX 1420
Obtained clean catch urine spec. for a Chem UA and C&S per Dr. Wong. Chem UA results: Color/yellow; Clarity/cloudy; SG/1.025; pH/7.0; Pr/1+; all other tests WNL. Sent spec out for a C&S to ABC Labs. Julie Harris, RMA
The following is an example of a lab log that may be used for a chemical urinalysis. LOG EXAMPLE: CHEM UA PT. #
DATE
DR
GLU
BILI
KET
BLO
SG
pH
PRO
URO
NIT
WBC
2056
01-12-XX
Miller
_
_
_
_
1.025
7.0
1+
_
_
_
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TABLE 4-2 Items Listed When Documenting In-Office Procedures INFORMATION TO BE DOCUMENTED
DESCRIPTION OR FACTS
1. Date and time of the procedure 2. Name of the procedure
May use standard abbreviations such as ECG, UA/C&S, and PFT testing.
3. Name of the provider ordering the procedure
You must always show an order for all procedures performed in the office. This is for legal and reimbursement purposes.
4. Locations when applicable
Applied splint to right arm, 6 steri-strips applied to left leg.
5. Special steps that were taken to perform the procedure
What solution was used to clean the wound, what ointment was applied to wound, and other steps.
6. Complications either during or following the procedure
Patients may have problems with certain procedures. Recording those problems will help other health care workers for future procedures.
7. Any educational information or home care instructions given to the patient
This is to demonstrate that the patient was given proper home care instructions.
8. Closing signature
First and last name, followed by your credential.
DOCUMENTATION EXAMPLE #1: CHARTING ROUTINE IN-OFFICE PROCEDURES
03-02-XX 1445
12-Lead ECG per Dr. Walker. Pt. was unable to lie in a supine position due to a neck injury thus was placed in a semi-fowler’s position. No complications during or following the procedure. Milli Thomas, SMA
Items Documented When Recording a Medication Entry Table 4-3 lists important components that should be included when documenting medications.
DOCUMENTATION EXAMPLE #2: CHARTING IN-OFFICE PROCEDURES
07-12-XX 1330
Steri-Strip application x 4 to the pt’s L. leg per Dr. Green. Irrigated wound with 60 mL of sterile H2O and dried with sterile gauze prior to the procedure. Applied “Tincture of Benzoin” to improve the adhesiveness of the strips. Good approximation of wound. Covered with sterile dressing and discussed home care instructions with pt. Pt. appeared to comprehend the instructions. Gave pt. written instructions as well. Pt. to return in 6 days for a F/U appointment. Taylor Steager, CMA (AAMA)
Documenting Prescriptions Medical assistants may have the task of calling in, writing, or transcribing prescriptions. All prescriptions, whether written, called in to a pharmacy, or e-mailed, should be documented in the patient’s chart. Whether or not the medical assistant is able to create prescriptions will be largely contingent on the type of prescription and the policy of the office. When assigned this task, the medical assistant must be diligent in maintaining patient safety and take precautions to minimize documentation errors. This chapter focuses on documenting prescription information in the chart. To learn more about writing prescriptions, see Chapter 32.
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E M R A P P L I C AT I O N The prescription writer within an EMR software program makes it easy to create and document prescriptions. Once the prescription is created the information is automatically filed in the appropriate log, saving the medical assistant an extra step.
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TABLE 4-3 Items Listed When Documenting a Medication Entry INFORMATION TO BE DOCUMENTED
DESCRIPTION OR FACTS
1. Date and time of administration
Timing is critical so that the patient receives the appropriate amount of medication within the proper time frame.
2. Name of medication
Write out the entire name to avoid confusion or misunderstandings. For example, if you write “Depo shot,” it could be read as Depo-Provero, Depo-Medrol, or Depo-Testosterone.
3. Strength of medication (dose given)
When the physician orders a particular strength of medication, it should be documented the way it was ordered. For example, the physician orders 100 mg of Toradol. It comes stocked as 100 mg per 1 mL of medication, so you give the patient 1 mL of medication. You should record it as Toradol,100 mg, not Toradol, l mL. Immunizations are usually recorded in milliliters (mL), such as 0.5 mL of adult tetanus toxoid. Allergy medications are usually recorded in mLs, such as 0.1 mL of allergy serum.
4. Route of administration
Was medication given intramuscularly (IM), subcutaneously (Sub-Q), intradermally (ID), intravenously (IV), or by mouth (PO)?
5. Site of administration
Where was the medication given? Right deltoid, L. dorsogluteal, etc.
6. Name of physician who ordered the medication
You need to show that you had an order to give the medication. If this information is not listed, it will appear as though you ordered the medication.
7. Manufacturer’s name, lot number, and expiration date (when applicable)
Some practices will want this information documented in the patient’s chart. Others will just have the medical assistant document this information into a medication log.
8. Any problems encountered
The medical assistant should document any local or systemic reactions, list the patient’s specific symptoms or signs, and document actions taken to counteract or ease the symptoms.
9. Any educational material distributed
Educational material may include immunization fact sheets, side effects to watch for after receiving certain medications, etc.
10. Closing signature
First and last name, followed by your credential.
DOCUMENTATION EXAMPLE #1: DOCUMENTING MEDICATIONS
06-26-XX 0900
Adult Hepatitis B Vaccine, 0.5 mL, IM, L Deltoid per Dr. Miller. SKB Manuf, Lot #98976, Exp, 01/XX. Gave pt. Hep B fact sheet. –complications during or following procedure. Catrina McDonald, RMA
DOCUMENTATION EXAMPLE #2: DOCUMENTING MEDICATIONS
12-10-XX 1335
Allergy serum, 0.3 mL, Sub-Q, R. arm per Dr. Kim. Observed a small wheal the size of a dime at the injection site during the post exam. –erythema, or rash at injection site. + warm to the touch. –dyspnea. Informed Dr. Kim of reaction. Dispensed one 50 mg caplet of Benadryl, PO per Dr. Kim. Pt’s husband will drive her home. Dr. Kim would like allergy dose reduced to 0.1 mL the next visit. Pt. to call with any problems. Alisha Muhammad, CMA (AAMA)
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Items Listed When Documenting a Prescription Order in the Patient’s Chart Table 4-4 lists items that should be listed when documenting prescription orders.
Documenting Patient Education Sessions Today we live in a society where patient education is essential. Managed care organizations and federal programs require providers to promote health maintenance by encouraging patients to have health care screenings
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and to participate in education sessions that promote overall health maintenance. This is particularly important in patients with diabetes, postmenopausal patients, and patients with heart disease. Examples of education sessions include teaching patients how to perform preventative screenings such as in-home breast and testicular exams. The medical assistant is being called upon now more than ever to deliver education to patients in a variety of ambulatory health care settings. The medical assistant must learn methods commonly used to
TABLE 4-4 Items Listed When Documenting a Prescription Order INFORMATION TO BE DOCUMENTED
DESCRIPTION OR FACTS
1. The date and the time that you called in the prescription or gave the patient a copy of the written prescription
This is important when the patient calls to see what time the prescription was called in to the pharmacy.
2. If calling in the prescription to a pharmacy, the pharmacy’s name, location, phone number, and pharmacist’s name
This will help to alleviate any misunderstandings as to which pharmacy was used.
3. Name of medication
Write out the entire name of the drug. Many drugs sound alike and using abbreviations could increase the risk of error.
4. Strength of medication
The strength should be clearly written so that the patient is not under- or overmedicated.
5. Amount to be dispensed
The amount to be dispensed is the amount of medication that the patient is to receive, such as the number of pills or amount of mL. You may write the numeral for the amount to be dispensed but it should also be spelled out to minimize confusion and to decrease the ability for someone to change the number.
6. Special instructions
This part of the prescription lists how the medication is to be taken and how much is to be taken per dose.
7. Number of refills
List the number of refills designated by the physician.
8. Who ordered the prescription
The medical assistant must show an order when documenting any medication orders.
9. Closing signature
First and last name, followed by your credential.
DOCUMENTATION EXAMPLE #1: DOCUMENTING A PRESCRIPTION ORDER
09-12-XX 1015
Called in Rx to ABC Pharmacy (South High Location), 292-6778. Spoke w/ pharmacist Julie Moore. TOPROL-XL, #30 (Thirty), Take 1 tab daily x 30 days per Dr. Stevenson. Ray Biggs, CMA (AAMA)
DOCUMENTATION EXAMPLE #2: DOCUMENTING A PRESCRIPTION ORDER
05-12-XX 1300
Written Rx: Ery-Tab, 250 mg, #40 (forty), Take 1 tab 4 times a day per Dr. Dorado. Tom Lehamn, RMA
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gather the resources for the sessions and techniques for delivering the information. See Chapter 9 for information regarding how to perform patient education sessions. This chapter will focus on how to properly document patient education sessions.
Items Included When Documenting Patient Education Sessions The documentation of patient education sessions is important for continuity of care and for legal purposes. If the patient develops a postoperative infection following a surgical procedure, and the procedure appears to be related to improper home care treatment, it will be very important to establish that the patient was properly advised on how to care for the wound either prior to or following the surgical procedure.
If the patient alleges that she was not told how to properly care for the wound and as a result developed a severe infection, the documentation in the chart may be the deciding factor in proving who is legally accountable. Care must be taken when entering this important information. Information that needs to be included for patient education sessions can be found in Table 4-5.
Documenting Telephone Calls Clinical staff members are often called upon to screen patient symptoms over the phone. This is an important task and medical assistants should have specialized training before attempting to perform telephone screenings. Medical assistant graduates should receive additional training on the proper procedure for screening phone calls in the offices in which they will
TABLE 4-5 Items Listed When Documenting Patient Education Sessions INFORMATION TO BE DOCUMENTED
DESCRIPTION OR FACTS
1. The date and time of the education session 2. The topic and purpose of the education session
For instance, smoking cessation, diabetes education, and medication management.
3. Who ordered the education session
This could be especially important if there is any kind of charge attached to the session.
4. Who was present for the education session
Family members quite often assist with home care. It is important to establish that family members as well as the patient are taught correct procedures for home care.
5. Patient’s comprehension and any reactions to the session
It is important to establish that those members in attendance understood the educational components that were delivered. This is usually accomplished by having the patient and family members in attendance repeat back the instructions.
6. Any educational materials that were distributed to the patient
Giving the patient educational materials helps the patient to remember the instructions at home.
7. Any verbal information that was given to the patient that wasn’t listed in the brochures
If special instructions were given, such as encouraging the patient to call with any questions or to follow-up in a certain time span, these should be noted in the chart.
8. Closing signature
First and last name, followed by your credential.
DOCUMENTATION EXAMPLE: DOCUMENTING PATIENT EDUCATION SESSIONS (ELECTRONIC ENTRY)
03-12-XX 1530
Breast health education session per Dr. Gutile. Demonstrated how to perform a breast self-exam and the signs to look for when performing a breast exam. Pt. appeared to comprehend the information and performed a successful breast exam on the breast model. Gave pt. breast health brochures and set up pt’s first baseline mammogram at Blackwell Radiology on 03-17-XX at 1400. Pt instructed to call with any questions. Molly Brown, CMA (AAMA)
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be employed. Medical assistants should never attempt to screen calls without the aid of an approved office protocol manual or telephone screening manual. Refer to Chapter 7 to learn more about how to thoroughly screen patient calls. Refer to Table 4-6 for a complete listing of what items should be included in the documentation of a telephone screening.
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Documenting Referrals A referral is a process in which one provider recommends the services of another provider, usually a specialist, to oversee certain aspects of the patient’s care. Some insurance companies or payers, particularly health maintenance organizations (HMOs), require
TABLE 4-6 Items Listed When Documenting a Patient Telephone Screening INFORMATION TO BE DOCUMENTED
DESCRIPTION OR FACTS
1. The date and time of the telephone call
Establish the date and time of the call in case the “timing of the call” becomes an issue in a legal dispute.
2. General complaint
A description of why the patient is calling. If talking to someone other than the patient, list the name of the person with whom you spoke (spoke with Emily’s mother, Mrs. Booker).
3. The responses to the screening questions listed in the protocol or telephone screening manual
Once the patient has stated the general complaint and duration of the symptoms, proceed directly to the protocol or telephone screening manual and ask the patient the corresponding questions that best match the patient’s complaint. Document the patient’s responses to each question. (If it is determined that the patient is in the middle of a lifethreatening emergency, do not proceed any further, but rather give the instructions listed in the action column of the screening manual.)
4. Confirmation of the patient’s medications and update medication list, if complaint is not urgent
The physician may decide to call in a prescription or suggest an over-the-counter (OTC) medication after receiving a list of the patient’s symptoms. It is important to update the patient’s medications ahead of time so that the physician doesn’t prescribe something that will interfere with another medication.
5. Update of the patient’s drug allergy status
It is important to have a listing of drug allergies so that the physician doesn’t prescribe something that could cause a serious reaction in the patient.
6. Instructions given to the patient and list the source from which the instructions came
Show that you were following approved protocol when giving information over the phone.
8. The patient’s comprehension of the instructions and the patient’s intentions in following the instructions
This is for legal purposes.
9. Closing signature
First and last name, followed by your credential.
DOCUMENTATION EXAMPLE: DOCUMENTING A TELEPHONE SCREENING
11-07-XX 1530
TC: Pt. c/o a continuous headache (10) x 2 days. “Pain starts in the front of my head and radiates to the back of my head.” +Nausea & Vomiting (3 episodes in last 2 hours). +Light sensitivity, –fever, –trauma, –neck pain, –sinus symptoms. No history of migraines. OTC: Tylenol Extra Strength 1000 mg every 4–6 hours. “Little relief.” No prescribed medications. Scheduled pt. for SDA per page 24 of screening manual. Pt. scheduled for 1630 appointment today with Dr. Song. Mary Brown, CMA (AAMA)
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the patient’s primary care provider (PCP) to make the request. The specialist usually has to be on the plan’s “Participating Provider List” in order for the insurance company to reimburse the specialist for the services. A referral may be completed over the phone, by faxing a statement, or through electronic means. The insurance company must approve the referral prior to the scheduled appointment date. Failure to seek approval for the referral can shift financial responsibility from the insurance company to the patient. Many insurance companies are now offering a plan that blends a preferred provider organization (PPO) and a managed care plan. This is commonly referred to as an “open access plan.” Under the open access plan, the patient may seek the care of a specialist without being required to obtain a referral from their PCP. The patient may be required to pay a higher copay with this type of plan, commonly referred to as a tiered copay.
Items Included on a Referral Request Form Referral requests are usually made by completing a form created by the office or supplied by the insurance company. The form may be faxed to the insurance company or sent electronically. Items that should be included on a referral request form include the following: 1. Patient’s name and date of birth 2. Subscriber’s insurance number and group number or name 3. ICD-9 code 4. Referring provider’s name, address, and National Provider Identifier (NPI) number 5. Referral provider’s name, address, and NPI number 6. CPT-4 codes for any procedures being requested
Items Listed When Documenting a Referral Documenting a referral is different from creating a referral. The referral form is sent to the insurance company and a copy is kept in the patient’s record. The documentation on the progress note illustrates that the referral was completed, the date it was completed, and whether it was approved. Table 4-7 lists items that are necessary when documenting a referral.
Documenting Precertifications Precertifications are also known as preauthorizations, predeterminations, or “precerts.” A precertification is a process in which certain procedures must be approved prior to being performed in order to have them covered by the insurance company. Precertifications are required by some managed care programs,
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FI E L D S M A R T S The referral appointment may be scheduled prior to payer approval; however, the patient should not be seen until authorization is obtained.
point of service plans, and governmental plans such as Medicare and Medicaid. A precert differs from a referral because it is specific to the procedure being performed. It is usually, but not always, initiated by the specialist’s office, unlike a referral, which is initiated by the primary care provider. Plans differ as to which procedures need to be precertified. Examples of procedures that may need to be precertified include hospital admissions, surgeries, some outpatient procedures such as MRIs, and physical therapy sessions. Contact the carrier’s provider or refer to the provider manual for specific details. The reverse side of the patient’s insurance card usually has a toll-free number that can be used for precertifications. Failure to obtain precertification for procedures mandated by the insurance company may result in large financial losses to the provider.
Information Necessary When Obtaining a Precertification The following list depicts information that is necessary when obtaining precertification from an insurance company. 1. 2. 3. 4. 5.
Patient’s name and date of birth Primary care provider’s name and ID number Specialist’s name and ID number CPT-4 codes for all procedures to be performed Number of sessions or days of inpatient status anticipated for hospital stays and extended care facility stays 6. Corresponding ICD-9 Dx codes for each diagnosis or ICD-9 Px codes for hospitalizations The carrier’s representative will either assign a precertification number or tell the medical assistant that the request must be forwarded for further evaluation. Hence, it is not a good idea to wait until the last minute to obtain precertification. Payment cannot be guaranteed until the precertification number is assigned. Even then, there is no guarantee that there will not be
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TABLE 4-7 Items Listed When Documenting a Referral INFORMATION TO BE DOCUMENTED
DESCRIPTION OR FACTS
1. The date and time of the referral 2. Method used to obtain the referral
Fax, telephone, or e-mail.
3. Name of referral provider
To whom is the patient being referred?
4. Name of referring provider
Who requested the referral?
5. Reason for referral/diagnosis
The diagnosis or condition.
6. Representative’s name who authorized the referral
Just in case a discrepancy arises, you have the name of the person to whom you spoke.
7. Authorization number
The number given by the payer representative who authorizes the patient to see the specialist.
8. Appointment date and time with the provider to whom the patient is being referred 9. Confirmation to patient of appointment
10. Closing signature
This is important in case the patient comes back and states that you never told them about the appointment. First and last name, followed by your credential.
DOCUMENTATION EXAMPLE: DOCUMENTING A REFERRAL
09-14-XX 1200
Faxed referral to Hum-Care for pt. to see Dr. Timothy McNight regarding patient’s COPD condi tion per Dr. Fein. Lacy McFarland from Hum-Care faxed back authorization code #23679. Scheduled pt. to see Dr. McNight on 9-22-XX at 1500. Called and verified this information with the pt. Shay Mullinar, SMA
some sort of out of pocket expenses to the patient. It is in the best interest of the office to have the patient sign a disclaimer that states that payment will be made according to the individual’s insurance plan. This will release the office from liability in cases when the insurance company pays only a fraction of the procedure’s actual cost.
Items Listed When Documenting a Precertification Once the precertification has been requested and approved, it should be documented in the patient’s chart. Table 4-8 lists items that should be documented for a precertification.
Documenting Outside Procedures There will be occasions when the patient will need to be scheduled at an outside facility to have particular procedures performed such as lab tests, x-rays, and certain diagnostic testing. The clinical medical assistant may be responsible for scheduling these procedures
and must check the patient’s insurance plan to determine if the patient should be sent to a participating provider (a facility that contracts with the insurance company to provide laboratory or diagnostic services) before scheduling the procedure. The medical assistant will also need to determine if the procedure needs to be precertified by the payer in order for reimbursement to take place. Once the medical assistant has checked the insurance coverage, the procedure should be scheduled and the patient should be notified.
Items Documented for Outside Procedures Refer to Table 4-9 to learn what items need to be documented for outside procedures.
Documenting Hospital Admissions The clinical medical assistant may be responsible for setting up a patient’s hospitalization. This may be in the form of a scheduled admittance for planned procedures or a direct admission for acute conditions or
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TABLE 4-8 Items Listed When Documenting a Precertification INFORMATION TO BE DOCUMENTED
DESCRIPTION OR FACTS
1. The date and time the precertification was requested
Most precertifications have time limitations, so dates are very important.
2. Name of carrier’s representative
This establishes a contact in the event of a problem.
3. Name of insurance company or payer 4. Name of procedure and where the procedure is to be performed
You need to show that authority was given to perform the procedure and list where the procedure can be performed (must use a facility approved by the payer).
5. Precertification number
The number given to the medical assistant that authorizes the patient to have the test.
6. If precertification is denied or detained, list reasons and options
This is important for follow-up purposes.
7. Closing signature
First and last name, followed by your credential.
DOCUMENTATION EXAMPLE: DOCUMENTING A PRECERTIFICATION
02-12-XX 1345
Obtained preapproval from Sandy Bernowski at JTH Health to schedule pt. for a uterine ultrasound at Hardy Memorial Hospital, per Dr. DiIullo. Certification #AD9087D4. Tim Peterson, RMA
emergencies. The medical assistant may also be responsible for obtaining preauthorization or precertification with the payer prior to the hospitalization. The following is necessary information for scheduling a hospital admission: ❖ Patient’s name ❖ Patient’s date of birth ❖ Patient’s current address ❖ Patient’s telephone number ❖ Patient’s social security number ❖ Name of payer and patient’s ID number ❖ Authorization code or number from the insurance company ❖ Referring or attending provider ❖ Primary care provider ❖ Location or facility patient is coming from ❖ Diagnosis ❖ Any special needs
be recorded in the chart when scheduling a hospital admission.
MAKING CORRECTIONS OR ADDENDUMS TO CHART NOTES
Items Recorded in the Chart When Scheduling a Hospital Admission
On occasion, it may be necessary to make a correction or an addendum to a previous chart entry. An addendum is an addition or supplement to a previous chart note. Health care workers should never paint correction fluid over an error, scratch over the error with a pen or marker, or rewrite the record. Applying those kinds of corrections could make it appear that the person making the correction is trying to hide something. Figure 4-6 illustrates an example of a note that has been corrected using the proper method for making corrections. When making a correction in a paper chart, do the following:
Hospital admissions should be recorded in the patient’s record. Refer to Table 4-10 for a list of items that should
1. Draw a single line through the error. 2. Write the correction above the error.
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TABLE 4-9 Items Listed When Documenting An Outside Procedure INFORMATION TO BE DOCUMENTED
DESCRIPTION OR FACTS
1. The date and time that the procedure was set up 2. Name of procedure(s) or test(s) to be performed
Examples: MRI of the brain and spinal cord, chest x-ray PA and lateral, tubal ligation, etc.
3. Name and location of facility performing the procedure and location within the facility where patient is to report
This is important because many health facilities have more than one location. It is also to give the patient information where they should report once they arrive at the center.
4. Name of person at facility who scheduled the procedure
This is important in case there are any problems.
5. Date and time of procedure
The date and time that the procedure is to be performed.
6. Name of provider ordering procedures
You must always show an order for any diagnostic or lab procedures in order for the insurance company to cover the procedures.
7. Any special instructions for the patient
Does the patient need to fast before the testing, follow special preparations prior to the testing, or arrive early to fill out the appropriate paperwork?
8. Confirmation to the patient
You will need to confirm that you have shared this information with the patient once the procedure is scheduled.
9. Closing signature
First and last name, followed by your credential.
DOCUMENTATION EXAMPLE: DOCUMENTING AN OUTSIDE PROCEDURE
05-22-XX 0900
Scheduled pt. for a uterine ultrasound at Washington Hospital on Tuesday 05-23-XX at 0800 on the 4th floor. Spoke with Judy Allen in the ultrasound lab. “Pt. should arrive 30 minutes early to complete the appropriate paperwork and should drink 4–6 glasses of water before arriving and bring a water bottle just in case the bladder is not completely full.” Called and confirmed this info with pt. Jessica Holtsberry, CMA (AAMA)
FIGURE 4-6 An example of the proper method for correcting an error in a paper chart
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TABLE 4-10 Items Listed When Documenting a Hospital Admission INFORMATION TO BE DOCUMENTED 1. Name of the hospital and location when applicable
DESCRIPTION OR FACTS Some hospitals have multiple locations.
2. Dates of admission 3. Reason for admission
The diagnosis or condition that created the need for the patient to be hospitalized
4. Provider ordering the admission
What provider ordered the hospitalization?
5. Person to whom you spoke to set up the admission
This is in case there are any problems.
6. Any special instructions given to the hospital
This would be details regarding the patient such as diet requests, requests for having the spouse room in, etc.
7. Any special instructions given to you by the hospital
Time for the patient to arrive and room number if applicable.
8. Closing signature
First and last name, followed by your credential.
DOCUMENTATION EXAMPLE: DOCUMENTATING A HOSPITAL ADMISSION
10-12-XX 1445
Spoke w/ Terry Pike in Admissions at Riverside Hospital (East). Scheduled pt. for direct admission regarding an acute flare up of colitis per Dr. Scottler. “Pt. is to go straight to the admission’s department upon arrival.” Pt. given written orders from Dr. Scottler to take to the hospital. Bianca Walker, RMA
3. Write the abbreviation CORR. beside the error and sign your name and credential and put the date on which you made the correction. The procedure for correcting or amending electronic entries will vary according to the program being used. A nice advantage of using computerized records is that until you finalize the note you can make all of the corrections you want, but once you click on the tab to complete the note, the information will be permanently stored within the system’s software. You can usually make addendums by clicking on the Addendum or Changes button within the patient’s individual file. The addendum function may allow you to add information but not change the contents of the original note. Some programs will allow you to make changes to the original note but stores all of the original notes so that they can be tracked for future reference.
DOCUMENTING AND SENDING FAXES On many occasions, the clinical medical assistant is responsible for sending fax messages or reports to other facilities. Data that may be sent via fax include lab reports, consultation reports, preadmission testing reports, and physical forms. The following are some guidelines for sending faxes: 1. Writing on the lead sheet should be neat and legible. Avoid spelling errors or words that are scratched out. Include the name of the person to whom you are directing the fax, the person’s title, and department. 2. Include your personal contact information and where you may be reached in the event of any ques-
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3. 4. 5. 6.
7.
8.
tions. Most fax cover sheets have the name of the office, telephone number, and fax number printed at the top of the form. Include the date you are sending the fax. List how many pages you are sending, including the fax lead sheet. Include any message that explains the purpose of the fax or special instructions. Ensure that there is a confidentiality disclaimer posted at the bottom of the fax cover sheet on any correspondence that contains protected health information. If the information is time-sensitive or if privacy is a major concern, call the party to whom you are faxing ahead of time so that she can position herself close to the fax machine for immediate retrieval. Never send unsolicited information through a fax machine.
WRITING AND SENDING E-MAILS The majority of health care facilities are now computerized, although exactly how computerized they are will vary from one facility to another. As a result of these technological advances, many businesses set up corporate e-mail accounts for each of their staff members. Much of the communication that takes place between medical office staff members is through corporate email. This saves a great deal of time because it allows the sender to communicate with other staff members without leaving the workstation. The medical assistant may have additional e-mail exchanges with professionals at other health care facilities, insurance companies, and patients. Before using corporate e-mail, the medical assistant should review the rules of proper etiquette when writing and sending corporate e-mails. They include: ❖ Be sure that e-mails are professional and do not contain any spelling or grammatical errors. ❖ Include a salutation and a closing when sending e-mails to outside facilities. ❖ Insert numbers or bullets when making a point. ❖ Avoid using all capital letters in e-mails, as this could be interpreted as shouting at the individual with whom you are corresponding (such as “DID YOU RECEIVE SAMPLE #541432 YET?”).
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FI E L D S M A R T S When sending fax reports that are time-sensitive or any reports that include important information, it is wise to save a copy of the transmission report. You can attach the copy to the patient’s chart under the appropriate tab or save it in a fax transmission file for easy reference.
❖ Avoid using common e-mail jargon or abbreviations that should be used only when sending personal e-mails. ❖ Avoid using emoticons in professional e-mails. ❖ Make certain that your subject line matches the content of your e-mail. ❖ Make certain that you attach your attachments, and always check with the recipient before sending large attachments so that you do not clutter their mailbox space. ❖ You should only use the high priority symbol (!) when you truly have a high priority e-mail. ❖ Send only work-related e-mails. In general, medical assistants should never use the Internet for personal endeavors while at work. This includes shopping online, checking or sending personal e-mail, or going to inappropriate Web sites.
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FI E L D S M A R T S With today’s technology, system administrators are able to track which Web sites employees visit and are even able to read personal e-mails that have been opened by the employee. Some systems are able to track this information even when the employee deletes it from the history component.
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Chapter Summary A large percentage of the communication that occurs in the medical office is through written communications. Documentation within the chart assists the provider with making a proper diagnosis and formulating a treatment plan. It is a communication tool used between health care employees to track the patient’s health care status and provides instructions to employees for performing various tasks. Documentation may set the stage for who wins a professional liability case; therefore, accurate and complete documentation is essential. It is important to learn common abbreviations and symbols used in health care, as well as abbreviations and symbols that are no longer acceptable due to the errors connected with their use. Learning early that spelling is vital and that documentation is just as important as the procedure itself will lead medical assistants to excel in the field of medical assisting.
FIELD APPLICATION CHALLENGE You have had a busy morning and the physician has pulled you away from your documentation several times to assist with special procedures. When you finally return to documenting, you find that you have transposed information for two different patients into a patient’s chart. The physician has already documented his information on the progress note and your information is written below the physician’s entry.
1. Would you rewrite both the physician’s entry and your entry onto a new progress note so that it is neat and free of errors? Why or why not? 2. If you wouldn’t rewrite the entire progress note, what would you do to correct the errors? 3. What are some things you can do to avoid this type of scenario in the future? 4. Would you alert the physician of the errors? Why or why not?
Chapter Assessment 1. Which of the following would not be considered a “Documentation Do”? a. Do document accurately. b. Do include the date and time for each entry. c. Do document subjectively. d. Do use only standard abbreviations that have been approved by the practice. 2. Which of the following items should be included when documenting an in-house procedure? a. The name of the procedure b. The location where the procedure was performed c. The storage cabinet from where you obtained supplies to perform the procedure d. Both a and b
3. Which of the following practices would be harmful to the provider if the record went to court? a. Documentation that was illegible and incomplete b. An error that had been scratched out and re-written c. A chart containing abbreviations that were on the “Do Not Use” abbreviations list d. All of the above 4. Which of the following should be included when documenting a laboratory entry in the patient’s chart? a. The name of the lab test b. Where the specimens were sent c. Any problems experienced during or following the procedure d. All of the above
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5. What items should not appear in a professional e-mail? a. The name of the person to whom you are sending the e-mail b. Emoticons c. Common e-mail jargon used in personal e-mails such as “lol” d. Both b and c 6. Which of the following should not be done when correcting an error in the chart? a. Draw a single line through the error. b. Record the date that you make the correction. c. Start a new progress note and rewrite the entry so that the entry doesn’t look messy. d. Place your initials next to the error.
Web Activities 1. Go to the Joint Commission’s Web site (www.jointcommission.org), look up the latest “National Safety Goals,” and write down at least four goals that could apply to medical offices.
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2. Download and print the latest list of “Error-Prone Abbreviations, Symbols, and Dose Designations” from www.ismp.com. 3. Using an Internet search engine, type the words “tips for good medical documentation” and research corresponding articles. Write a one-page paper on tips for good documentation. Share your findings with other members of the class.
CONNECTION Using your StudyWARE CD-ROM: ❖ Complete the Hangman and Crossword Puzzle activities for this chapter. ❖ Complete the Quiz for this chapter in Test Mode.
C H A P T E R
Conducting a Patient Interview and Developing a Medical History Chapter Outline Therapeutic Communication The Use of Body Language and Therapeutic Communication “Touching” in a Therapeutic Environment Stages of the Patient Interview Stage I: Preparation Stage II: Greeting and Introduction Stage III: Body of the Interview Stage IV: Conclusion Incorporating Effective Interviewing Techniques Effective Questioning Techniques
Ineffective Questioning Techniques Effective Listening Techniques Tools Used to Collect Medical History Information Types of Health Histories The Comprehensive Medical History Personal Medical History Family Medical History Social History
5 Essential Terms body language comprehensive medical history emergency health history episodic medical history family medical history genogram gesture interval health history past history (PH) or past health history (PHH) personal medical history proxemics social history therapeutic communication usual childhood diseases (UCD or UCHD)
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KEY COMPETENCIES Conducting a Patient Interview and Completing a Patient History Form
CAAHEP
ABHES
III.C.3.c.4.c
VI.A.1.a.4.a
Interview effectively
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VI.A.1.a.2.f
Developmental Objectives After completing this chapter, you should be able to: 1. Correctly spell and define the essential terms. 2. Explain how therapeutic communication improves the interviewing process. 3. Discuss how proxemics is influenced by culture and specific settings. 4. List three types of body language and discuss what role body language plays in communication. 5. List and describe the four stages of the patient interview. 6. Identify and describe three types of questioning techniques and list examples for each technique. 7. List and describe eight different types of ineffective questioning techniques and explain why they are ineffective. 8. List various senses that are used during listening and why active listening is so important during the interview process. 9. Identify and describe four different listening techniques and list examples of each technique. 10. List two methods that are used to collect patient data. 11. Describe four types of patient histories and describe when each method is used. 12. List and describe three parts of the medical history. 13. List five questions that should be posed when a patient answers Yes to a disease or condition during a health history. 14. Develop a family history using the genogram method. 15. Describe why the social part of the history may be more sensitive than other parts of the history.
Introduction The medical history is one of the most important documents found in the patient’s chart. It gives providers an instant replay of diseases and conditions that the patient has encountered from the time of birth to the time that the history is developed. Figure 5-1 illustrates a medical assistant performing a history on the patient. The patient’s personal, family, and social history are explored for possible clues in determining what ails the patient. The history also assists the provider in predicting future ailments and an opportunity for intervention that will either prevent or delay these possible conditions from occurring.
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part of the patient during the interview process. The medical assistant should display a trustful and compassionate demeanor and convey to the patient that all information collected during the interview will remain confidential. Medical assistants must choose their words wisely and make certain that their body language is congruent with what is being stated verbally.
The Use of Body Language and Therapeutic Communication
FIGURE 5-1 An important task of the medical assistant is to take the patient’s history.
The role of the medical assistant in regard to the medical history may be that of a collector, that is, to collect related history data from the patient and place it in the appropriate section of the chart, or that of an interviewer, to complete the history form for the patient or to review the form once it has been completed by the patient, making certain that all questions have been answered and all Yes responses have been developed. This is accomplished by asking a series of questions that are specifically related to the disease or disorder that is marked. In order to become an effective interviewer, the medical assisting student will need to learn proper techniques for interviewing patients and learn the importance of strong communication skills. This chapter will provide the medical assisting student with important information to become proficient at performing this vital task.
THERAPEUTIC COMMUNICATION To be an effective interviewer, the medical assistant must first understand the importance of therapeutic communication. Therapeutic communication may be best described as an exchange of information between the health care worker and patient that leads to the advancement of the patient’s physical and emotional well-being. In order to communicate on a therapeutic level, the medical assistant must learn how to create an environment that promotes active cooperation on the
Webster’s defines body language as “gestures, postures, and facial expressions by which a person manifests various physical, mental, or emotional states and communicates nonverbally with others.” The use of body language is important during the patient interview. Body language can change the meaning of what is conveyed verbally. Studies suggest that less than 10% of what is perceived during a communication encounter is actually spoken while over 90% is the direct result of body language and tone of voice. Body posture should be direct, open, and relaxed while still maintaining a professional posture. Medical assistants should avoid facial expressions or body language that make it appear that they are bored or preoccupied. Eye contact should be frequent, though excessive eye contact may be interpreted as staring, causing the patient to feel uncomfortable. Touching may be used in instances where the medical assistant wants to convey concern or compassion, but may seem insincere if overly used or used in an inappropriate manner. Figure 5-2 illustrates a medical
FIGURE 5-2 This medical assistant does not appear to be interested in what the patient has to say.
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Anglo Americans emphasize the importance of good eye contact, but medical assistants must realize that not all cultures feel the same. Asian, Middle Eastern, Hispanic, and some Native American cultures may frown on excessive direct eye contact. In Asian cultures, looking someone directly in the eye may imply that you feel equal to or superior to the person. Direct eye contact from a female medical assistant may lead a Middle Eastern male to conclude that she is being sexually suggestive.
assistant whose body language suggests that she isn’t interested in what the patient is saying.
“Touching” in a Therapeutic Environment There may be times that “touching” is acceptable in a therapeutic environment. Touching helps convey concern or compassion toward a patient who is anxious, in pain, or is emotionally distraught. Patients may break down during the interview process due to a painful
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CR ITI C A L TH I N K I N G C H AL LEN G E The provider just revealed to the patient that his test results came back positive for cancer. The provider leaves the room and the patient begins to cry. You lean over and give the patient a tissue. You take your hand and gently pat the patient’s shoulder. The patient shrugs his shoulder and moves away from you. 1. What signal is the patient trying to send? 2. What would be an appropriate response from you at this point? 3. Is there anything that you can do to assist the patient?
Many Hispanics avoid long periods of direct eye contact as a way of demonstrating respect for another person. Because some Native American cultures believe that the eye is a window into the person’s soul, looking directly into another person’s eyes could cause the soul to be stolen. Keep in mind that not everyone from the same culture will have the same beliefs, especially those who have been in the United States for a long period of time.
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memory or out of fear of their pending diagnosis. A touch may provide comfort or even demonstrate to the patient that the medical assistant truly cares about what they are experiencing. Appropriate touching may include a pat on the shoulder, holding a patient’s hand, or hugging a patient. Refer to Figure 5-3 for examples of gestures that can be used to convey a caring attitude toward the patient. The medical assistant must learn when touching is appropriate and watch for signs that may indicate the patient’s discomfort over such gestures. Learning techniques to improve therapeutic communication will enhance the interviewing process and allow the medical assistant to obtain the maximum amount of information that will assist the provider in the diagnosis, treatment, and health maintenance of the patient.
STAGES OF THE PATIENT INTERVIEW The patient interview involves four stages, which include: Preparation, Greeting or Introduction, Body of the Interview, and Conclusion. A thorough medical assistant will incorporate all four stages into the interview process.
Stage I: Preparation Patients will often feel apprehensive when visiting the physician, especially during new patient visits. It is important for the medical assistant to create an atmosphere that helps place the patient at ease.
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FIGURE 5-3 Various “touching” gestures can convey compassion for the patient.
Begin by selecting a room that is private and free of distractions. Check the room’s appearance. Make certain that it is clean, neat, and free of odors. The
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C U LT U R A L AWA R E N E S S If a patient has a language barrier, an interpreter that speaks the patient’s native language will need to be available to assist with communication. Some patients may use family members that are bilingual to aid with communication; however, this may not be a good idea. The family member may not possess the language skills that are essential for “effective communication.” Also the patient may not feel as free to speak if a family member is in the room. Watch for signs that could suggest the patient’s discomfort with the person performing the interpreting. Share your findings with the provider.
thermostat for the room should be set at a temperature that is comfortable for the patient. There should be a comfortable chair for both the patient and the patient’s spouse when applicable. If the patient is to have a special procedure performed, procedure trays should be placed out of the view of the patient. Trays that are left in the open could trigger the patient to become anxious and less focused on accurately communicating medical history information.
Stage II: Greeting and Introduction The greeting and introduction is an important part of the interview process. This stage sets the tone for the remainder of the interview. Medical assistants may extend a greeting by shaking the patient’s hand (Figure 5-4), introducing themselves, and stating their title, but hand shaking may not always be appropriate. Some people will feel uncomfortable with hand shaking due to cultural beliefs or fear of disease transmission. The greeting may take place in the reception room or in the examination room if someone other than person performing the history takes the patient back to the exam room. Address adult patients by using their title
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FIGURE 5-4 Upon meeting the patient for the first time, this medical assistant extends her hand to shake the patient’s hand.
(Mr., Mrs., Dr., and so on) followed by their last name. Children should be addressed by their first name. The medical assistant should ask the patient how they prefer to be addressed for the remainder of the interview and for future visits. Take a little extra time to document this information in the chart so that anyone working with the patient in the future will be cognizant of the patient’s preference. Acknowledge family members or friends that may also be present.
Many EMR programs have a special place to insert personal notes. This may be identified in the EMR software as “Patient Notes” (Figure 5-5) or “Personal Notes.” This is a good place to insert how the patient wants to be addressed during office visits and to list special events in the patient’s life such as a wedding or special vacations. Having this information noted in the EMR will remind you to inquire about the special event upon the patient’s return. In order for this EMR functionality to be useful, always check the personal note section before retrieving the patient.
Once introductions are complete, the medical assistant will work toward building trust with the patient. Inform the patient that all information shared during the interview is confidential and will not be shared with anyone other than the provider. Whenever possible, medical assistants should position themselves at the same level as the patient.
FIGURE 5-5 A screen from an EMR program with a section where patient notes can be entered, such as how to address the patient and special events coming up in the patient’s life (SynapseEHR 1.0 screen shots courtesy of E.S. Butler.)
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F IELD SM A RTS You may need to discourage certain family members or friends from being present during the interview process. The patient may be hesitant to answer questions honestly if a family member or friend is present. This is particularly true for adolescent patients, who may feel uneasy about a mother or father being in the room and may shut down when asked particular questions. On the other hand, having a relative such as the patient’s spouse or adult child may be
Proxemics is another factor that should be considered prior to being seated. E. T. Hall, an expert in proxemic behavior defines proxemics as, “The way people use space in their environment.” In simplified terms, proxemics refers to the amount of space a person needs
helpful when dealing with geriatric patients or patients suffering with forms of dementia. The office will usually have a policy regarding who may be present during patient interviews and examinations. Learn the policies of your office and always be respectful and tactful in those instances when you need to ask a family member or friend to leave. Inform them that they will be invited back to speak with the provider at the conclusion of the examination.
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to feel comfortable when standing or sitting next to another person. Hall concluded in his study that there are four interpersonal distances that are important during social encounters. Table 5-1 lists those four types of distances
TABLE 5-1 The Four Interpersonal Distances
CIRCUMSTANCES
ACCEPTABLE DISTANCE BETWEEN YOU AND THE PATIENT
Intimate distance
Direct contact to 1.5 feet
Intimate distance in our personal lives usually refers to the distant that is appropriate for hugging, kissing, and love making. During health encounters, there may also be times when intimate distance is considered appropriate. The extension of a hug or assisting the patient during a wheelchair transfer are instances in which intimate distance may be acceptable.
Personal distance
1.5 to 4 feet
Personal distance is usually considered appropriate when communicating with close friends and family members. In health care, this closeness may be necessary when performing specific procedures such as phlebotomy, blood pressures, and catheterizations. Even though the medical assistant may be touching the patient with his hands, his body is still a couple feet away from the patient’s body.
Social distance
4 to 12 feet
Social distance is the usual distance that you would stand from another person during a social encounter. This distance is also considered appropriate for patient interviews.
Public distance
Greater than 12 feet
Public distance may be used when working with a group of people. This distance is not commonly used in a medical practice but may be used in a classroom while providing education for a group of patients.
EXAMPLE
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C R I T I C A L T H I N K I NG CHALLENGE
If the patient has a hearing aid, he should be encouraged to wear and adjust it prior to the start of the interview.
and also describes when those distances may be appropriate during health care encounters. Since the patient interview is considered a social encounter, the interviewer’s chair should be placed approximately 4 to 12 feet from the patient’s chair. This distance may not be attainable if the exam room is particularly small. If the patient has a hearing impairment, the medical assistant may need to sit in closer proximity to the patient so that the patient does not have to strain so hard to listen to what the medical assistant is saying. Medical assistants must be aware of the importance of proxemics and work hard to create an environment that is comfortable for each patient.
Stage III: Body of the Interview The body of the interview, also called the working stage, consists of the questioning and answering stage of the interview and is the stage where the bulk of data is collected. A good interviewer will keep the patient on task during the interview process. It is sometimes easy for the patient’s answers to begin to drift during questioning. The medical assistant may need to gently steer the patient back to the original line of questioning. Avoid expressing surprise or disapproval at some of the patient’s responses. Remember that each person is unique and has been exposed to a whole different array of environmental factors than you may have experienced. Societal, cultural, and spiritual influences all play an important role in the decisions that individuals make throughout their life span. It is not the medical assistant’s role to judge the patient but rather to care for the patient.
Stage IV: Conclusion During the final few minutes of the patient interview, the medical assistant will summarize and validate information that was collected during the body of the interview and give the patient an opportunity to add any additional concerns. At the conclusion of this stage, the medical assistant should inform the patient of what to
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You are interviewing a 13-year-old male patient during the health history. His mother is in the room during the interview. You notice that the young man is barely answering questions. Instead, his mother is answering. The patient appears frustrated that his mother continues to stay in the room. The mother realizes she needs to run out to the car. 1. How could the mother staying in the room during the entire history impact therapeutic communication? 2. What questions might you ask the patient while the mother is away? 3. How might you gently steer the mother to the reception area when she returns?
expect for the remainder of the visit and provide the patient with disrobing instructions. The medical assistant should thank the patient for their cooperation during the interview and ask the patient if there are any questions. If there is going to be a delay before the provider enters, offer the patient some reading materials to ease the passing of the wait time.
INCORPORATING EFFECTIVE INTERVIEWING TECHNIQUES Becoming an effective interviewer is a skill that needs to be developed over a period of time. Medical assisting students should practice taking patient histories several times throughout the training process so that by the time they graduate, they are comfortable with the process.
Effective Questioning Techniques Effective questioning is necessary to facilitate good exchange between the patient and medical assistant. The medical assistant should display interest and concern regarding what troubles the patient. For instance, one might respond to a patient by saying, “Mrs. Jones, it sounds as though you have gone through a rough time this past month.” Interest in what the patient is saying can be demonstrated both verbally and nonverbally. Reinforce your concern by gently patting the patient on the shoulder or arm.
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A gesture is a sign, signal, or cue that is used to communicate in combination with or apart from words. Gestures help to enhance the message that is being sent and are often incorporated during the questioning phase of the patient interview. There are three types of questioning techniques that can be incorporated during the interview to help facilitate patient responses. Table 5-2 identifies those techniques and lists examples.
Ineffective Questioning Techniques Just as good communication techniques encourage patient input, poor communication techniques impede the communication process. Table 5-3 lists examples of ineffective interviewing techniques.
A good listener is an active listener. Active listening involves more than just your sense of hearing; it encompasses other senses as well. Observe the patient’s facial expressions and body language as they respond to certain questions. Does the patient’s body language match what is being stated verbally? Active listening sometimes requires the medical assistant to respond to a patient’s response with an additional question to fully understand the patient’s original response. Refer to Table 5-4 for effective listening responses.
Effective Listening Techniques
TOOLS USED TO COLLECT MEDICAL HISTORY INFORMATION
Listening is a difficult skill to master. It requires the medical assistant to enter the interview process with a clear mind. You cannot be an effective listener if your mind is wandering during the interview.
There are two types of tools that are used to collect data for the patient history. The first is the standard paper medical questionnaire, which requires the person completing the form to write in the correct responses.
TABLE 5-2 Effective Questioning Techniques TECHNIQUE
ABOUT THE TECHNIQUE
EXAMPLES
Asking open-ended questions
Ask this type of question when you are opening up the interview. Open-ended questions often begin with what, when, how, where, and who, and often elicit a more comprehensive response.
“What brings you to the office today, Mr. Jones?”
Asking close-ended questions
You should avoid asking close-ended questions unless it is necessary to expand on a response that was given after asking an open-ended question. This type of question can frequently be answered with a yes or no response or a singleword answer. You should be careful not to overuse these questions because they restrict the patient’s response and may make the patient feel as though you are controlling and uninterested in what the patient has to say.
Effective: “How many episodes of vomiting have you had over the past two days?” or “On a scale from 1 to 10, how would you rate your pain?” Ineffective: “Would you say that your rash is better than the last time you were here?”
Periods of silence
Periods of silence can also be effective during the questioning phase of the interview. It demonstrates that you are still waiting on a response while allowing the patient time to think about the question.
Medical Assistant: “Out of all your symptoms, which symptom is bothering you the most today?” Patient: “I don’t know, they all give me grief.” Medical Assistant: (silent) Patient: “Oh gee, probably my foot pain.”
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TABLE 5-3 Ineffective Interview Techniques TECHNIQUE
ABOUT THE TECHNIQUE
EXAMPLES
Asking leading questions
This may indicate a desired response rather than the patient’s real feelings.
“Megan, please tell me that you are not sexually active, are you?”
Demanding an explanation
This may appear to threaten or challenge the patient to justify a response for certain actions.
“Why didn’t you come in sooner for this condition?”
Agreeing or disagreeing with the patient
It is not your job to side with or against a statement made or a feeling expressed by the patient.
“I am in total agreement with you, Mrs. Jones,” or “I don’t think that you should go on vacation when you are eight months pregnant.”
Interrupting the patient
You should allow patients to complete their train of thought. Interrupting minimizes the value of the patient’s input and may suppress important information.
Medical Assistant: “Has anyone in your family ever been diagnosed with cardiovascular disease?” Patient: “Well, my sister’s husband . . .” Medical Assistant: “No, we only want to know about blood relatives.”
Using medical terminology
Patients often do not understand medical terms. The patient may not ask for interpretation because of being fearful that the medical assistant will think he is unintelligent or uneducated. Use terms that can be easily understood by the patient.
“Have you noticed any edema in your ankles, Mr. Lacy?”
Diagnosing the patient
You must be careful to never offer an opinion regarding what may be wrong with the patient. Medical assistants do not have a license to practice medicine.
“I bet you just have a case of the stomach flu, Mrs. Wilson. It’s been going around.”
Advising the patient
You must be careful to never advise patients on what procedures to have or what medications to take.
“I use calamine lotion when I have poison ivy.”
Offering false reassurance
When patients are uneasy or anxious about a condition or procedure, you may want to ease the patient’s anxiety by offering reassurance. However, you must never promise that everything is going to be just fine or that you are certain there will be no problems when a certain procedure is performed. Statements like these can set up the office for legal problems if problems are incurred.
“Mrs. Bean, I know everything is going to be just fine. There is no need to worry.”
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TABLE 5-4 Effective Listening Techniques LISTENING TECHNIQUES
DESCRIPTION
EXAMPLE
Clarification
Clarification means to clear confusion or uncertainty. This is a process that is used when the patient uses a phrase or term that needs further interpretation or the patient sends mixed signals either verbally or nonverbally.
Patient: “I have a weird feeling when I go to the bathroom.” Medical Assistant: “What do you mean by ‘weird feeling’?”
Restating
Restating means to state again or to state in a new form. This is repeating or rephrasing the main idea of the sentence and validating what the patient just stated. It also lets the patient know that you are listening to what they are trying to convey.
Patient: “I am so tired and weak and just do not feel like doing anything.” Medical Assistant: “So, you feel tired and weak?”
Reflecting
Reflecting means to ponder or think. Reflecting gives the patient an opportunity to expound on something that is bothering him and stimulates the patient to revisit his original thought.
Patient: “I just want to give up the fight. I am sick of taking all these pills every day.” Medical Assistant: “Mr. Baker, do you really want to give up?” Patient: “No, I don’t want to give up, but I am sick of taking all of these expensive horrible pills every day.” Medical Assistant: “You sound upset, Mr. Baker. What is upsetting you the most: the expense of the medication or taking the pills?”
Summarizing
This listening response is usually incorporated at the conclusion of the interview. It recaps the patient’s concerns. This listening component helps to separate what is relevant from what is irrelevant.
Medical Assistant: “Okay, Mrs. Jones, so your main concerns today are your inability to lose weight and your high blood pressure readings. Is that correct?”
This form may be initially completed by the patient and then further developed by the medical assistant or provider. The second tool used to collect patient data is the computer. The electronic history is a major component found in many EMR programs. The computerized medical history may be completed by the patient prior to the appointment if the patient has access to a computer, or it may be completed in the examination room using an electronic kiosk. The medical assistant or provider will review the electronic history with the patient and make certain that all information is accurate.
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FI E L D S M A R T S Sending the health history form to the patient’s home a few days before the appointment allows the patient time to carefully read the questions and formulate responses. It also provides the patient with an opportunity to research information that he is unsure about, such as hospitalization dates, family illnesses, etc.
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Many electronic medical histories allow the person completing the information to select various diseases and conditions from a list (Figure 5-6). When the user clicks on a Yes response, another set of questions may pop up on the screen that expounds further on that particular condition or disease. Electronic histories can be developed in a quicker time frame than the standard paper history, and they are easier to read. Computerized histories can be easily updated without creating a great deal of work for the person updating the information.
TYPES OF HEALTH HISTORIES There are four types of medical histories: 1. The comprehensive medical history: This is a complete health history that covers the patient’s personal, family, and social history from the time of birth until the time that the history is developed.
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This is usually performed on the initial visit and updated every one to two years thereafter. Refer to Figure 5-7 for an example of a comprehensive medical history form. 2. The episodic medical history: Whenever a patient comes in with a new health problem such as a fever or sore throat, an episodic history is taken. The episodic history is the chief complaint in combination with the history of the present illness (HPI). The medical assistant usually provides the subjective information (chief complaint); however, the provider is normally responsible for developing the history of the present illness. 3. The interval health history: Also called the follow-up health history, this type of history builds on a complaint from a previous visit. It may also be referred to as a progress note. 4. The emergency health history: This is the type of history information collected by emergency
FIGURE 5-6 A screen shot of a completed history from an EMR program (SynapseEHR 1.0 screen shots courtesy of E.S. Butler.)
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FIGURE 5-7 A paper-based comprehensive history form
staff members in an emergency room or urgent care center. It provides the triage team with vital information for diagnosing the patient’s condition and for prioritizing the order in which patients are seen. History formats may also vary according to the specialty of the practice. Some specialties will emphasize questions that parallel with their particular specialty.
THE COMPREHENSIVE MEDICAL HISTORY The comprehensive or complete medical history is a head-to-toe look at the patient and is divided into three major sections: 1. Personal medical history 2. Family medical history or family history (FH) 3. Social history (SH)
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Personal Medical History The patient’s personal medical history includes the patient’s previous health concerns, current health concerns, and a current medication list. Previous health concerns include the patient’s past history (PH) also known as past health history (PHH). This part of the history includes usual childhood diseases (UCHD or UCD), previous major illnesses, previous injuries, previous surgical procedures, and immuniza-
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tion information. Current health concerns include a review of systems (ROS) or systems review (SR) and the patient’s chief complaint (CC). The ROS is a list of symptoms that coincide with different body systems that the patient is currently experiencing or has experienced in the past year. This part of the history is completed by the provider. The medical assistant is usually responsible for entering the chief complaint, which is a brief description of why the patient is being
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seen. When asked to elaborate on the patient’s past medical history, use Table 5-5 to elaborate on Yes responses. Refer to Table 5-6 for information that should be gathered when developing the current medication listings, allergy listings, surgical listings, and hospitalizations.
Family Medical History The family medical history provides detailed information about the present and past health of the patient’s family members. The family history can provide insight to possible risks of future diseases or conditions for the patient. Medical histories should include a minimum of two to three generations whenever possible. The family history should contain the age and health status of living family members and list the age at which
nonliving members died and their cause of death. Family members should include siblings, parents, grandparents (both paternal and maternal), aunts, uncles, and children. Some history forms also include information regarding the spouse’s health status. Knowing more information about the spouse’s health will assist the provider in knowing possible links to environmental health factors and may provide the provider with important information for the level of stress that a patient may be under, such as caring for an ill spouse. There are two documentation formats that are used to develop a family history. The first is the traditional health history questionnaire, which asks a series of questions followed by Yes and No boxes. The second format is the family tree or genogram. The genogram method has two major components, the family tree and a list of familial diseases. Refer to Figure 5-8 for an example of a genogram.
TABLE 5-5 Questions That Should Be Asked When a Patient Responds with a Yes to a Particular Symptom, Disease, or Condition QUESTION
DEFINITION OR INFORMATION ABOUT THE QUESTION
Exact name of symptom, disease, or condition
Many questionnaires are categorized to include only general information such as, “Have you ever experienced heart problems?” If the patient indicates Yes, list the name of the disorder.
Duration of illness or condition
How long ago was the patient diagnosed with the particular illness or condition?
Course of treatment
What type of treatment did the patient receive to remedy the condition or illness (medication, surgery, diet, etc.)? If the patient had a surgical procedure to remedy the condition, list the name and date of the procedure and the name of the provider who performed the procedure.
Current status of the illness or condition
Does the patient still suffer from this condition or illness?
Date of resolve (if applicable)
List time frame or date of resolve when applicable.
DOCUMENTATION EXAMPLE: The patient marked a Yes response to Glaucoma. The medical assistant expanded on the response by entering the following information: Glaucoma
X No __ Yes __
Glaucoma diagnosed in March of 2008. Treatment: Argon laser trabeculoplasty in May 2008; Performed by Dr. Lee Wang. Current Treatment: Eye Drops and Vitamins. Last Eye Exam: May 2009 “Pressures were normal during the last exam.”
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TABLE 5-6 Additional Information Expounded upon When Developing the Current Medication Listings, Allergy Listings, Surgical Listings, and Hospitalizations EXAMPLE OF DOCUMENTATION ON THE HISTORY FORM
LISTING
DEFINITION
Current medications
Listing all of the patient’s current prescribed, over-the-counter, and homeopathic medications. Be certain to spell each drug properly and list the strength and how often the patient takes the drug.
Prescribed Medications: Avandia, 4 mg, 1 tab twice a day Triglide, 160 mg, 1 tab/day Quinapril, 40 tab, 1 tab/day OTC Medications: 1 multivitamin/day 1 aspirin/day
Allergies
May be broken down into “Drug Allergies” and “Other Allergies.” All drug allergies should be flagged using red ink. Provide details regarding what occurs when the patient takes the medication. (In some instances what the patient considers to be an allergy to the medicine is actually a side effect.) “Other Allergies” include allergies to latex, mold, pollen, foods, plants, animals, and insects. If the patient has been formally tested for allergies, provide details of testing. Drug allergies and latex allergies should be flagged on the cover of the chart.
Drug Allergies: Penicillin (hives, throat swells, difficulty breathing)
Surgical history
List type of surgery, date of procedure, name of surgeon, where the surgery was performed, and any complications.
Surgical Procedures: Appendectomy, 03-07-01, Dr. Carl Valentine, Riverside General, no complications
Hospitalizations
List dates of hospitalizations, name of hospital, reasons for and length of hospitalization, and any complications.
Hospitalizations: 07-15-08: Riverside General Hospital, double pneumonia, hospitalized for 6 days, no complications
Other Allergies: Mold (confirmed through allergy testing in 1999) Dust (confirmed through allergy testing in 1999)
FIGURE 5-8 An example of a completed genogram Steven
Edna
68
67
MI
Hypertension Diabetes
Hal
Judy
Linda
Roger
39
38
45
47
Good health
Heart trouble
Mild hypertension
Asthma
Sue
Ben
Janet
Laura
Trent
11
14
16
20
17
Diabetes
Good health
Good health
Good health
Diabetes
Female
Male
Deceased
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Patients may go to www.hhs.gov/familyhistory to download a tool called, “My Family Health Portrait.” Entering personal and family health data into this computerized template creates a personalized medical history form that can be used throughout the patient’s life span. The form, which can be updated when changes occur, assists the provider in predicting future ailments and provides an opportunity for intervention that will either prevent or delay these possible conditions from occurring. Patients
Information that should be obtained when gathering health data about each family member should include: 1. The family member’s current age or age at the time of death 2. All diseases or disorders for each family member 3. If family member is deceased, the cause of death Example:
Family Member Father
Health Status or Deceased Fair
Mother
Fair
Maternal grandmother
Deceased
Current Age or Age at Diseases or the Time Disorders of Death (Cause of Death) 66 Hypertension and diabetes 64 Hypertension and MVP 77 Cause of death: Heart attack Other diseases: Hypertension and breast cancer
Social History The social history refers to lifestyle questions. Lifestyles can have a large impact on the prevention or launching of certain diseases or conditions. Patients
should print a copy of the history and take it with them when visiting new providers or whenever changes occur in their medical history. The surgeon general recommends that families work together in developing their family histories. This allows family members to compare data for accuracy. The holidays are a great time of year to work on this project because it is one of the few times a year that family members are all together.
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frequently feel anxious during this part of the interview due to the sensitivity of the questioning. The medical assistant must possess a professional demeanor throughout the entire interview but must work especially hard during this part of the interview to convey trust, integrity, and an unbiased attitude. The medical assistant must in no way demonstrate condemnation toward the patient’s lifestyle choices. Nor should the medical assistant employ jokes that may make the patient feel uncomfortable.
Parts of the Social History The patient’s social history may be subdivided into several different categories. The number of categories and depth of questioning will depend on the form used and the preferences of the provider. Table 5-7 lists questions that may be included in this part of the history. Another form of questioning that assists the provider in determining the patient’s susceptibility to disease is community health questions. Studies reveal that living in areas with high pollution indexes or greater or lesser amounts of sunshine can increase or decrease the patient’s risks for developing certain diseases or disorders. Providers need to be alerted when a patient states that the community in which he lives has a high incidence of cancer, for instance. Refer to Procedure 5-1 for the steps for interviewing a patient and taking a medical history.
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TABLE 5-7 Parts of the Social History PARTS OF THE SOCIAL HISTORY
COMMON QUESTIONS INCLUDED
Alcohol use
List what type of alcohol the patient consumes (beer, wine, hard liquors) How much alcohol is consumed weekly and how often does the patient drink alcohol? Example: “6 to 10 12-ounce cans of beer per week”
Tobacco use
Age of onset What form of tobacco does the patient use (pipe, cigars, cigarettes, chewing tobacco, etc)? How much does the patient smoke or chew per day? Has the patient ever quit smoking? If so, how long ago and for how long? What caused the patient to start smoking again? Is the patient currently interested in a smoking cessation program? Example: “1 to 2 packs of cigarettes/day x 10 years.” Pt. is interested in a smoking cessation program.
Caffeine intake
List the types of beverages that the patient drinks that contain caffeine. How many of those beverages does the patient consume on average per day? Example: 3 12-ounce cups of coffee/day and 2 to 3 16-ounce bottles of Mountain Dew/day.
Drug abuse or recreational drug use Remind the patient that this information is completely confidential. Some providers may want to develop this part of the history themselves.
Name of drug and amount of usage. If past history of drug abuse, list time frame of usage and if the patient was ever in drug rehabilitation. Example: Pt. states that he used marijuana on a casual basis from 1990–1994. Pt. denies current usage of any illegal drugs.
Work history Certain occupations may stimulate particular industrial diseases. Examples of occupations that may cause health risks include construction workers who work with asbestos, and coal miners, farmers, or horticulturists who work with harmful chemicals.
State the hazardous occupation and how long the patient has worked in the environment or had worked in the environment. List any known illnesses that were provoked as a result of working in the hazardous environment. List patient’s noise level if relevant. Example: Pt. is a retired coal miner who worked in the coal mines for 30 years. Was diagnosed with “black lung” 5 years ago. Under the care of Dr. Herbert Zangmiester (pulmonologist).
Seatbelts The provider wants to know what safety practices the patient follows to help prevent disease and injuries. This is usually just a Yes or No response. If the patient answers with a No response, find out why the patient does not wear a seatbelt.
Record if the patient uses a seatbelt. If not, list reason for not wearing seatbelt. Example: Regular Use of Seatbelt: Answer, No Pt. states that seatbelts feel too constraining and that he cannot drive with a seatbelt on.
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TABLE 5-7 Parts of the Social History (continued) PARTS OF THE SOCIAL HISTORY
COMMON QUESTIONS INCLUDED
Firearms Similar to seatbelts. The provider wants to know what the patient does that could put that patient at higher risk of disease or injury.
Example: Firearm Practices: Answer, Yes Pt. is a hunter and owns several shot guns and semi-automatic rifles. Pt. states that all firearms are locked up along with ammunition when not in use and that he follows safe practices when using firearms.
Sexual practices Some providers may prefer to complete this section of the form.
Describe the patient’s sexual orientation: heterosexual, homosexual, bisexual. Risk stratification: monogamous relationship (one partner), multiple partners, etc. Barriers: Condoms (sometimes, always, never) What form of birth control does the patient use, if any? Example: Sexual orientation: Heterosexual in a monogamous relationship with husband x 10 years, no barriers, patient’s husband had a vasectomy 5 years ago.
Diet
Is the patient on any special therapeutic diets? How many meals does the patient eat per day? Does the patient like to snack? What does the patient snack on and when? Has the patient’s weight fluctuated in the past year? Example: Pt. eats 2 meals/day (lunch and dinner). Eats approx 2 to 3 snacks/day (cookies, candy bars, potato chips). Weight gain of 5 pounds in the past year.
Exercise
Does patient participate in a formal or informal exercise program? What type of exercise does the patient do? How often does the patient exercise? Example: Exercise: Answer, Yes, Walks on treadmill 3x/week, 30 min per session.
PROCEDURE 5-1 Conducting a Patient Interview and Completing a Patient History Form Objective: To accurately complete a comprehensive medical history form while promoting good therapeutic communications.
Equipment/Supplies: ❖ Patient history form ❖ Writing instruments
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RATIONALE
1. Wash hands and prepare the interview area. The interview area should be private, comfortable, and free of distractions. The furniture should be set up to accommodate the patient and anyone who may be with the patient. The medical assistant’s chair should be at least 4 to 12 feet away from the patient’s chair.
Properly preparing the room will make the patient feel more comfortable and more receptive to answering the questions.
2. Once the patient has been escorted to the examination room, identify yourself, list your title, and identify the patient using two different identifiers. Ask the patient if he has a certain preference for the way he wants to be addressed throughout the remainder of the interview and future visits.
It is important for medical assistants to identify themselves and to list their title so that the patient knows that they have authority to perform this task.
3. Explain the purpose of the history and inform the patient that everything that is shared during the interview will remain confidential.
Explaining the purpose of the history will help the patient to understand why the information is necessary. Letting the patient know that information will remain confidential will help the patient feel more at ease when discussing the more sensitive information.
4. If the patient completed the form prior to the visit, review all information and check for possible omissions or incomplete responses. If the medical assistant is completing the entire form, address all questions on the form.
Patients may have omitted important information or possibly misunderstood certain questions. Reviewing the form and expanding on applicable responses will help save time for the provider later on.
5. Properly develop all Yes responses in the past medical history section. List the exact name of the disease or condition, duration or onset of the disease, treatment, current status, and date of resolve if applicable.
Properly developing the Yes responses will save the provider a great deal of time.
6. Properly expand on all Yes responses listed in the family and social history sections.
Properly expanding on all Yes responses will save the provider time.
7. Make certain that either you or the patient lists all current prescribed medications and over-thecounter drugs that are being taken by the patient. List their strengths and how often the patient takes the medication.
It is important to list all medications being taken by the patient. Certain OTC medications can cause serious side effects, so it is important for the provider to have a complete listing.
8. Make certain that all drug and other types of allergies are listed under the appropriate section and that drug allergies are either highlighted or written in red ink.
It is important that all drug and latex allergies stand out so that the provider doesn’t prescribe something for the patient that they are allergic to.
9. Make certain that all hospitalizations and surgeries are listed on the medical history form.
Offices will vary. Some providers will want you to list all hospitalizations and all surgeries. Other providers will omit normal baby deliveries as part of the hospital and surgery section, unless the patient had a cesarean section.
10. List the patient’s chief complaint.
Find out specifically what prompted today’s visit.
11. Once the form is completed, summarize the information with the patient.
Summarizing the information will help to confirm that the information is factual.
12. Ask the patient if he would like any additional information added to the history form.
This gives the patient an opportunity to address anything that was not listed on the form and confirms that what the patient states is important. continues
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PROCEDURAL STEPS
RATIONALE
13. Thank the patient for their assistance during the interview process. 14. Instruct the patient how to disrobe prior to the exam. Give the patient some reading materials if time permits, and properly exit the room.
Chapter Summary An effective interviewing technique is a skill that must be developed in order to become proficient at completing patient histories. Some providers will want to develop their own patient histories, while others will depend on the interviewing skills of the medical assistant to develop the history. Medical assistants who possess good interviewing skills will save the provider a great deal of time. Patients need to feel confident that the information that they share with members of the health care team will remain confidential and that health care team members will not be judgmental toward the patient regarding information that they share during the interview.
FIELD APPLICATION CHALLENGE You interview a Middle Eastern couple. The wife, who is the patient scheduled to have an immigration physical, can speak English, but you notice that the husband is answering the majority of questions. The patient is quiet during the interview. You do not feel as though you are connecting with her. At the end of the interview, you ask her to remove all articles of clothing from the waist up. You notice that the husband becomes agitated. He asks you if the patient is seeing a female or male physician. You tell him that Dr. Jones is a male physician. The husband tells you that his wife will not be removing any clothes today and that if you insist, they will leave.
1. Should you have asked the husband to leave during the patient interview? Why or why not? 2. Could you have done anything differently to elicit more responses from the patient? 3. How should you respond when the husband refuses to allow his wife to disrobe? 4. Why do you think that the husband is reacting in the manner that he is?
Chapter Assessment 1. During the patient interview, the medical assistant notices that the patient moves his chair several inches further away from where the medical assistant placed it. What should the medical assistant do? a. Ask the patient to put the chair back where it was before. b. The medical assistant should move his chair closer to the patient. c. Do not acknowledge that the chair was ever moved.
2. What should you do if you notice that a Native American male patient will not look at you when responding to your questions? a. You should tell the patient that he needs to look at you when responding to your questions. b. You should look away from the patient. c. Since you recognize that this is may be a cultural issue, you continue the questioning and minimize direct eye contact.
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3. Which distance is considered acceptable for performing patient interviews? a. Intimate distance b. Personal distance c. Social distance d. Public distance 4. What is the average distance between the patient and the body of the medical assistant when performing blood pressures? a. Direct contact to 1.5 feet b. 1.5 to 4 feet c. 4 to 12 feet d. Greater than 12 feet 5. The bulk of the data is collected during which stage of the interview? a. The preparation stage b. The greeting and introduction stage c. The body of the interview d. The conclusion 6. The type of questioning technique that is usually used at the beginning of the interview is referred to as: a. open-ended questions. b. close-ended questions. c. silence. 7. Which of the following would be considered ineffective interviewing techniques? a. Asking leading questions b. Demanding an explanation c. Strongly agreeing or disagreeing with the patient d. All of the above 8. What is the name of the listening technique that stimulates the patient to ponder on their last response? a. Clarification b. Restating c. Reflecting d. Summarizing 9. What type of family history is also considered a family tree? a. Famogram b. Genogram c. Genofam d. None of the above 10. What information would be included in the patient’s personal medical history? a. Past medical history b. Review of systems c. Current medication listing d. All of the above
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Web Activities 1. Go to the www.hhs.gov/familyhistory Web site and download a copy of “My Family Health Portrait.” Complete your own personal health portrait and place it in a file that you can retrieve to take with you for future medical office visits. Complete a fictitious form making up several different health problems. Print a copy of the fictitious form and give a copy to your instructor. 2. Put the following words into a search engine: “E.T. Hall and the study of proxemics.” Pull up one of the articles that describe Professor Hall’s research on proxemics and complete a one-page report summarizing your findings.
CONNECTION Using your StudyWARE CD-ROM: ❖ Complete the Concentration and Crossword Puzzle activities for this chapter. ❖ Complete the Quiz for this chapter in Test Mode.
THE DVD LINK On your StudyWARE CD-ROM, go to the DVD Challenge for this chapter. View the DVD clip and respond to the following questions: 1. What types of tasks should be performed to ready the exam room for the next patient? 2. What should the medical assistant do to the pap tray so that the patient is not distracted by the tray during the patient interview or history? 3. What additional form may need to be completed prior to the history form? 4. What did you think of Anita’s personality? 5. What did Anita hand to the patient so that she could figure out her LMP?
C H A P T E R
Developing In-Office Screening Skills Chapter Outline Establishing Boundaries The Role of the Medical Assistant during In-Office Screenings Developing the Chief Complaint Documenting Findings from the Initial Screening
Improving Anticipation Skills and Following Office Protocol The Provider’s Role during the Assessment Process The Follow-Up Appointment/ Progress Note
Developmental Objectives After completing this chapter, you should be able to: 1. Correctly spell and define the essential terms. 2. Establish the boundaries of the medical assistant during in-office screenings. 3. List the parts of an in-office screening. 4. Explain how slightly developing the chief complaint can assist the medical assistant with anticipating how the patient should disrobe and what instruments and supplies may be necessary during the exam. 5. Describe the provider’s role in the assessment process. 6. State why the provider must develop her own HPI and list components of the HPI. 7. Describe the role of the medical assistant during the follow-up interview. 8. List and define the parts of a follow-up progress note.
6 Essential Terms anticipation skills duration history of the present illness (HPI) standing order subjective information symptom
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KEY COMPETENCIES
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ABHES
Conducting and Documenting an In-Office Screening
III.C.3.c.4.a
VI.A.1.a.2.f VI.A.1.a.4.ff
Conducting a Follow-Up Interview and Developing a Progress Note
III.C.3.c.4.a
VI.A.1.a.2.f VI.A.1.a.4.ff
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Introduction The medical assistant will quite often be responsible for screening patients prior to the provider’s examination and assessment. The role of the medical assistant during the screening process is to take the patient’s chief complaint and, in some instances, develop a brief history of the present illness (HPI). Medical assistants need to learn basic screening questions that correspond with particular body systems. By developing the chief complaint, the medical assistant will be able to develop good anticipation skills—the ability to know what the provider needs without having to ask.
ESTABLISHING BOUNDARIES The medical assistant has many responsibilities during in-office screenings but must be careful to stay within the boundaries of the position. The medical assistant’s function during a patient visit is that of a screener, and the medical assistant must never go beyond that role. Patients put a great deal of faith in members of the medical office team. It is important that medical assistants refrain from sharing their beliefs on what could be wrong with the patient. It is also important to avoid prescribing medications or treatments either intentionally or inadvertently by suggesting any prescribed or over-the-counter remedies. Medical assistants must also resist the temptation to perform any testing or procedures without a direct order from the provider. Medical office employees may become relaxed in their relationships with particular providers after being employed for a long period of time, but must never feel so comfortable that they feel that they have authority to order or perform a test based on what the provider has ordered in the past under similar conditions. Staying within the boundaries of medical assisting is essential to prevent harm to the patient and possible revocation of certification or registration status to the medical assistant. Refer to Figure 6-1 for a set of boundaries that medical assistants should stay within when conducting patient interviews and anticipating the needs of the provider.
THE ROLE OF THE MEDICAL ASSISTANT DURING IN-OFFICE SCREENINGS The role of the medical assistant during in-office screenings will vary according to the guidelines of the practice. However, in most cases, the initial screening will consist of the following: obtaining the patient’s chief complaint, updating the patient’s current medication list, updating the patient’s allergy status, and
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Diagnostic Testing without an Order
Diagnostic Testing with a Physician’s Order
Physical Assessment
Patient Histories
Patient Preparation
Prescribing Vital Signs
Diagnosing
Screener Chief Complaint
FIGURE 6-1 This football field illustrates boundary lines for what a medical assistant can do in regards to patient screenings. The out-of-bound markers illustrate what the medical assistant cannot do.
performing and documenting the patient’s vital signs. The medical assistant will also be responsible for having the patient disrobe appropriately and for setting up any equipment, instruments, or supplies for the exam.
Developing the Chief Complaint The chief complaint or reason that prompted the patient to seek medical attention is referred to as subjective information because it is information that is supplied by the patient. Symptoms are a list of signals or signs experienced by the patient that are indicative of a specific disease or condition and may include, pain, fever, itching, and a host of other physical or mental ailments. The medical assistant is usually responsible for recording the chief complaint but may also be responsible for performing a brief history of the present illness (HPI), which is a series of symptoms that are related to the patient’s complaint. Developing a brief HPI will assist the medical assistant in knowing how to properly prepare the patient and set up the room for the examination. The provider, however, will need to thoroughly develop the HPI for reimbursement purposes. There may be occasions when patients complain of multiple problems during the initial screening. This is particularly difficult if the patient only mentioned a single problem at the time the visit was scheduled.
It is unlikely that the provider will be able to address all of the patient’s concerns during the current visit due to time constraints. Depending on office protocol, the medical assistant may need to ask the patient what problem troubles her the most, and then direct the patient to schedule another visit, at the conclusion of the current appointment, to address all remaining concerns.
TOOL BOX
E M R A P P L I C AT I O N With EMR, the medical assistant has the ability to schedule the patient’s appointment directly from the point of care. Offering to schedule the appointment yourself lets the patient know that you personally will make certain that there is enough time allotted during the follow-up visit to address all remaining concerns. It may also soften the sting of not addressing all of the problems voiced during the current appointment and help to convey to the patient that you truly care about the remainder of the concerns.
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complaint will vary from office to office, so always check the policy of the office in which you are working.
Documenting Findings from the Initial Screening Table 6-1 lists items that should be included when documenting the findings from the initial screening. In Table 6-1, items marked with the “*” symbol are considered part of the HPI and might not be recorded by the medical assistant. Whether or not the medical assistant will be responsible for recording the HPI portion of the
Documenting the Date and Time Medical personnel recording in the chart will normally use a six- or eight-digit numeric system for recording the date (01/12/10 or 01/12/2010).
TABLE 6-1 Items That Should Be Documented When Performing an In-Office Screening WHAT SHOULD BE DOCUMENTED
DESCRIPTION
1. The date and time of the visit
Military time is commonly used in the medical industry, especially in hospitals, because of its preciseness. Refer to Figure 6-2 for a military conversion clock. Always check the policy of the office in which you are working.
2. The chief complaint or reason for the visit
This is a description of what is wrong with the patient, using the patient’s own words whenever possible.
3. *Duration or date of onset
How long the patient has noticed symptoms or when the injury occurred.
4. *Related symptoms
This is a list of common symptoms that coincide with the patient’s complaint. Related symptoms should only be documented if it is the policy of the office for the medical assistant to do so. If it is not the office policy, you should still ask pertinent questions to gain proper anticipation skills. Refer to Table 6-2 for a listing of related symptoms that coincide with specific body systems or parts.
5. *What makes symptoms better or worse (OTC medications, lying flat, walking, etc.)
Knowing what makes the symptoms feel better or worse may assist the provider with a diagnosis and determining what treatment is appropriate.
6. A listing of all of the patient’s current medications. (This may only need to be documented within the patient’s medication log. Check institutional policies.) Medications should include all prescribed and OTC medications along with the dosage and how the patient is taking the medication.
The patient’s medication status often changes from one visit to the next. Patients may see more than one provider, each of whom prescribes drugs related to their area of specialty. Patients may try new over-thecounter medications or herbal supplements, which can interfere with the responses of other drugs when taken in combination.
7. Any drug allergies. Record this information in red; it may be displayed at the top of the progress note form and on the cover of the chart.
Patients may develop allergies at any time.
8. Closing signature
Will vary depending on the place of employment but may include the entire first and last name followed by the credential.
*Part of the HPI
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TOOL BOX
F IEL D S M A R T S Even though you may not be responsible for developing the HPI portion of the complaint, knowing how to develop the complaint will assist you in preparing the patient for the exam, anticipating the needs of the provider, and taking phone calls from patients that are ill. The provider will likely appreciate your thoroughness and attention to detail.
Military time is the time measurement system used by the military but it may also used by emergency personnel, hospitals, and other medical establishments. The reason many medical establishments use military time is because it is more concise and less ambiguous than standard time. Standard time uses the numbers 1 to 12 to identify each of the hours in a 24-hour period. Military time uses the numbers 00 to 23 (or may use 01 to 24) to identify each of the hours within its system. Midnight under military time would be expressed as 0000 (or as 2400), and 1:00 a.m. would be expressed as 0100. 12:00 p.m. would be expressed as 1200 in military time and 1:00 p.m. would be expressed as 1300. Minutes and seconds are expressed exactly the same for both time systems, so 12:01 a.m. would be expressed as 0001 in military time and 1:15 p.m. would be expressed as 1315. The a.m. and p.m. are unnecessary when using military time. Refer to Figure 6-2 for a military conversion clock.
Documenting the Chief Complaint or Reason for the Visit The reason for the visit is a brief summary of the patient’s symptoms. The beginning of this part of the complaint should be in the patient’s own words. The medical assistant may briefly develop the complaint by expanding on some of the general information that the patient has shared. Items such as location, amounts, color, size, and the patient’s pain rating may be developed during this segment of the screening; however, the provider will develop these sections much more thoroughly once she assesses the patient. Documenting Location The medical assistant should list the general location of the symptoms. For example, if the patient states that she is having ear pain, the med-
1 11 12 24 10 2223 1314 2 15 3 9 21 16 20 8 19 18 17 4 7 6 5 SM. Taylor
AUTOSET
FIGURE 6-2 This clock is an illustration of a 24-hour clock.
ical assistant should determine which ear is symptomatic. This will provide the physician with a heads-up before entering the patient’s room. The provider will usually confirm this initial evaluation and expound on information that requires more specific details during her portion of the assessment and examination. Documenting Amounts The patient’s perception regarding amounts may be quite different from the medical assistant’s or provider’s perception. Take for example the patient who complains of “vaginal hemorrhaging.” The term hemorrhage usually indicates that the patient is losing massive amounts of blood and that emergency intervention may be necessary. The medical assistant should ask the patient to elaborate to establish whether the patient is truly in the middle of an emergency crisis. To help better evaluate the situation,
TOOL BOX
FI E L D S M A R T S Never make patients feel that you are downplaying their symptoms. Your point of reference is entirely different from the theirs. Your responsibility is to care for patients and to remain professional at all times.
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the medical assistant may ask the patient questions such as: “What type of pads or tampons are you using? How many pads or tampons are you going through per hour?” Suppose the patient states that she is going through four pads per hour. If after more elaborate questioning the medical assistant finds out that the pads are mini-pads, that will be much less alarming than if the pads are overnight pads. Developing the complaint will assist the medical assistant in determining if emergency intervention is necessary and in knowing how to set up the room. Documenting Color Color may be important when discussing body fluids. When the patient states that she is bringing up phlegm when she coughs, the medical assistant should ask the color of the phlegm. If the phlegm is colored, it may indicate infection and the provider may want to order a sputum culture or chest x-ray. As a result of expanding the complaint, the medical assistant can be proactive in gathering the forms and supplies that are necessary to set up the probable procedures. This can save time if the provider gives an order following examination of the patient. If the provider does not order tests, the medical assistant can simply return all of the forms and supplies to their original location at a time when it is convenient to do so. Remember to never perform any test unless you first receive an order from the provider to do so. Documenting Size Size is always important when describing related information. The patient may state
FIGURE 6-3 A numeric pain intensity scale can be used for patients who can read and understand numbers.
0 No pain
1
2
3
4
5 Moderate pain
6
7
8
9
10 Worst possible pain
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that they are passing large blood clots. “Large” is another term that carries some ambiguity and can mean different things to different people. It is best if the medical assistant asks the patient to use an object such as fruit or coins for comparison (for instance, “Mrs. Baskins, if you were comparing the size of your clots to a coin, which coin would be most comparable in size?”). Documenting Pain Pain is subjective and some patients have a hard time expressing their pain. Patients with a good understanding of numbers may refer to a numeric pain intensity scale (Figure 6-3) to describe the intensity of their pain. Children or patients with language barriers may have a hard time understanding the numeric pain scale so the practice may use the Wong-Baker FACES Pain Rating Scale (Figure 6-4) or something comparable. This scale uses faces to describe the amount of pain the patient is experiencing.
Documenting Duration or Date of Onset The term duration refers to the period of time that the patient has experienced symptoms and is an important factor in the screening process. It assists the provider in determining a diagnosis and also aids the provider in determining the course of treatment. Duration is part of the HPI, so whether or not the medical assistant will record this information will be determined according to office protocol.
Documenting Related Symptoms Questioning patients about potentially related symptoms will aid the medical assistant in determining what organs or body systems are involved so that the medical assistant can better prepare the patient for the examination. Because this portion of the screening is part of the HPI, the medical assistant will need to follow office protocol regarding entering this information in the chart.
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PAT I E N T P E R S P E C T I V E I am a migraine sufferer who has been through several pain management programs throughout the past 10 years. I am on a new pain management program that greatly reduces the number of migraines I typically experience, but once in a while the medication does not work and I need to have medical intervention in order to obtain
Table 6-2 lists common symptoms that coincide with different body systems. The table is designed to assist the medical assistant with screening patients during in-office and telephone screenings. The symptoms are related to a body part or system so that the medical assistant can anticipate the needs of the provider prior to examination. When the chart lists possible procedures under anticipatory guidelines, it is referring to procedures that may be requested prior to the conclusion of the patient’s visit. Gathering supplies, equipment, and forms for these procedures ahead of time will save time in the event that the provider orders a procedure. Remember that medical assistants should never perform any tests or procedures without a direct order from the provider.
relief. It is bad enough to be in horrific pain, but it is even worse when members of the medical staff look at me as though I am a “drug seeker.” Please do not judge my motives or my level of pain. You can’t know the pain that I am in without walking in my shoes.
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herbs, and aspirin. Some providers will want medications recorded on the progress note either above or below the chief complaint. Others will want the information recorded directly onto the medication log. When recording medications, the medical assistant must be certain to record the name and strength of the drug and how the patient takes the medication.
Listing Drug Allergies Patients can develop a drug allergy at any time, so it is important to inquire about drug allergies on a regular basis. Patients may become agitated, stating that they already provided the information on a prior visit. Calmly explain that they can develop allergies at any time so it is important to check this information periodically
What Makes Symptoms Better or Worse Sometimes it is helpful for the provider to know what makes the patient’s symptoms better and what makes the patient’s symptoms worse (this includes any OTC remedies that the patient is taking). This is another part of the HPI, so medical assistants should check office protocol before listing this information.
Listing All Current Medications It is important for the provider to have an updated listing of all the patient’s current medications, including prescribed and OTC medications such as vitamins,
TOOL BOX
F IEL D S M A R T S Any sudden onset of severe head pain, back pain, or abdominal pain should be evaluated by the provider as soon as possible.
TOOL BOX
C R I T I C A L T H I N K I NG CHALLENGE While you are performing an in-office screening, the patient states that she is having horrific abdominal pain. The patient is doubled over and clenching her abdomen. The pain came on suddenly, and the patient is also complaining of nausea, vomiting, and a fever. The patient tells you she is thirsty and asks you if you can get her some water. There are two other patients in front of this one. 1. Should you talk to the provider about this patient before she goes in with the other two patients? If so, why? 2. Should you give the patient something to drink? Why or why not?
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TABLE 6-2 Common Screening Questions That Coincide with Specific Body Parts or Systems and Anticipatory Guidelines BODY PART OR SYSTEM
COMMON SCREENING QUESTIONS
ANTICIPATORY GUIDELINES*
Breasts
Pain, tenderness, swelling, drainage, odor, change in size, fever, any dimpling? Any history of breast disease?
Disrobing instructions: Remove all clothing from the waist up. Vital signs: Blood pressure (never take a BP on the same side as where a patient has had a mastectomy; it can cause a condition known as lymphedema) Other measurements: Weight Possible equipment and supplies: Culture supplies if drainage is present Possible outside procedures: Mammogram, breast ultrasound, breast biopsy
Cardiovascular
Difficulty in breathing, shortness of breath, chest pain or pressure, radiation of pain to arms, neck, or jaw, heart palpitations, nausea or vomiting, swelling in hands or feet, fainting episode? Any history of cardiovascular disease?
Disrobing instructions: Remove all clothing from the waist up. Vital signs: All Other measurements: Weight (if not an emergency) Possible equipment and supplies: Crash cart, artifical external defibrillator (AED), ECG unit, pulse oximeter (instrument used to measure blood gases), oxygen equipment, and IV materials Possible procedures: ECG, pulse oximetry, defibrillation, and CPR
Ears
Hearing deficits, ringing in the ear, pain or discharge, build up of earwax, or a possible foreign body in the ear? Any history of ear disorders?
Disrobing instructions: None Vital signs: Temperature and blood pressure Other measurements: Weight, audiometry (test that measures hearing) if applicable Possible equipment or instruments: Otoscope to examine the ear and audiometer to check hearing. Ear irrigation equipment, irrigating solution, and gauze if the patient has a build-up of cerumen (earwax) or a foreign body in the ear. Irrigating solution should be warmed a couple degrees above normal body temperature. Possible procedures: Ear irrigation (when there is a build-up of cerumen)
Endocrine
Physical or mental weariness, weight fluctuations, heat/cold intolerance, excessive sweating, an increase in hunger or thirst, an increase in urination, heart palpitations, increase in heart rate, bulging eyes, tearing eyes, increase of body hair or changes in body hair distribution, swelling in the neck area? Any history of endocrine disorders?
Disrobing instructions: Remove all clothing except for undergarments. Vital signs: All Other measurements: Height and weight Possible lab: If the patient exhibits signs of diabetes, the provider may want an in-office blood glucose performed. The provider may order other blood tests for related symptoms.
Eyes
Visual disturbances, double vision, light sensitivity, excessive tearing, night blindness, drainage, foreign body in eye, blind spots, halos around objects, blood shot eyes? Any history of eye disease? Question the patient regarding the use of contacts and eye glasses and record the date of the patient’s last professional eye exam.
Disrobing instructions: None Vital signs: Blood pressure Other measurements: Weight, visual acuity testing (test that measures the patient’s vision) Possible equipment and supplies: Cycloplegics (dilating agents), fluorescein dye, sterile swabs, gauze, pen light, ophthalmoscope, and antibiotic drops If the patient has a foreign body: May set up for an irrigation, which includes irrigation equipment, irrigating solution (sterile saline, or sterile water), drapes, and gauze Comfort instructions: Turn lights down or off until the provider enters the room. continues
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TABLE 6-2 Common Screening Questions That Coincide with Specific Body Parts or Systems and Anticipatory Guidelines (continued) BODY PART OR SYSTEM
COMMON SCREENING QUESTIONS
ANTICIPATORY GUIDELINES*
Female reproductive
Start with an OB-GYN history. Record the number of pregnancies (Gravida), the number of live births (Para), and the number of miscarriages or abortions (AB). If the patient takes birth control or hormone therapy, list the type and strength. List the patient’s last menstrual period (LMP) and information regarding the following: time span intervals between periods, duration of periods, amount of blood loss, and any unusual symptoms such as mood swings prior to or during the cycle. Other menstrual questions may include: Menarche: The age at which the patient’s periods began Menopause: The age or month and year the patient’s periods stopped May also ask patients about hot flashes, any decrease in sex drive, mental concentration, or vaginal dryness GYN questions: Vaginal pain, discharge, or unusual odor, pain during intercourse, any urinary symptoms, abdominal or lower back pain, fever? OB questions: Date of confinement or due date? Any nausea or vomiting? Swelling in hands feet or face? Any unusual discharge?
GYN patients: Disrobing instructions: If the visit is for an annual pap and pelvic, remove all clothing, including undergarments. If the patient is exhibiting vaginal symptoms, remove clothing from the waist down. Vital signs: Blood pressure Other measurments: Weight or height and weight (for menopausal women) Possible equipment and supplies: Pelvic tray with cultures, if applicable Possible procedures: Pelvic exam and collection of STD cultures Possible lab procedures: Urinalysis when patient complains of urinary symptoms. Send out STD cultures when cultures are collected. OB patients: Disrobing instructions: Remove all clothing for the first visit, expose the belly for subsequent visits until week 36, remove clothing from the waist down for all remaining visits Vital signs: Blood pressure Other measurements: Weight Possible equipment and supplies: Fetal monitor, gel, gauze, tape measure, ultrasound unit Possible laboratory procedures: Chemical UA (for glucose and protein) Possible procedures: Ultrasound
Gastrointestinal
Nausea or vomiting, diarrhea, constipation, change in bowel habits, black tarry stools, the expulsion of gas, belching, heartburn, difficulty in swallowing, gastric or abdominal pain, hemorrhoids? Any history of GI disorders?
Disrobing instructions: Remove all clothing except undergarments if symptoms appear to be above the waist. If there are any rectal or anal symptoms remove undergarments as well. Vital signs: Temperature and blood pressure Other measurements: Weight Possible equipment and supplies: Anoscope (instrument to examine the anus) or proctoscope (instrument to examine anus and rectum) when patient complains of anal or rectal symptoms Comfort instructions: If the patient is nauseated or has been vomiting, provide an emesis basin or trash bag and wet washcloth Possible lab procedures: Blood work, stool cultures, or other stool tests when symptoms are related Possible procedures: Anoscopy or proctoscopy if symptoms are related to the anus or rectum Alert: Never give a patient with acute abdominal pain anything to eat or drink unless approved by the provider.
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TABLE 6-2 Common Screening Questions That Coincide with Specific Body Parts or Systems and Anticipatory Guidelines (continued) BODY PART OR SYSTEM
COMMON SCREENING QUESTIONS
ANTICIPATORY GUIDELINES*
General
Include a review of all systems to determine which systems are involved.
Disrobing instructions: Remove all clothing; may leave on undergarments. Vital signs: All Other measurements: Height and weight Possible equipment and supplies: Scales, ophthalmoscope, otoscope, tuning fork, percussion hammer, tape measure, (disposable gloves, hemoccult cards, developer, and lubricant if rectal exam is performed), (disposable gloves, vaginal tray, and supplies if vaginal exam is performed) Possible lab work: Lab testing related to the patient’s age and symptoms Possible procedures: Procedures related to the patient’s age and symptoms
Hematological
Easy bruising, fatigue, shortness of breath, fever, joint pain? Any history of hematological disorders?
Disrobing instructions: Remove all clothing, may leave on undergarments. Vital signs: All Other measurements: Weight Possible lab testing: Blood testing related to the patient’s condition
Lymph nodes
Enlargement, tenderness, fever, joint pain, any other symptoms?
Disrobing instructions: Remove clothing to expose affected areas. Vital signs: All Other measurements: Weight Possible lab procedures: Blood work related to the patient’s symptoms
Male reproductive
Testicular pain, penile discharge, urinary symptoms, lower abdominal pain, lower back pain, fever, or pain during intercourse? Any history of male reproductive disorders?
Disrobing instructions: Remove clothing from the waist down. Vital signs: Blood pressure Other measurements: Weight Possible equipment and supplies: Disposable gloves, STD culture swabs and plates Possible lab work: Urinalysis and urine culture if urinary symptoms are present; related cultures if penile symptoms are present
Musculoskeletal
Injury: Pain or swelling of the affected area, skin discoloration, loss of feeling or tingling, and description of the injury? General: Joint pain, swelling, stiffness, weakness? Any history of musculoskeletal disorders?
Disrobing instructions: Remove clothing to expose affected areas. Vital signs: All Other measurements: Weight Equipment or supplies: Casting materials or splints for possible fracture; Wrapping materials for possible strain or sprain Possible procedures: X-rays of affected areas, splinting, casting, or wrapping procedures
Nose and sinuses
Cold symptoms, postnasal drip (describe color and viscosity), stuffiness, sinus pain or pressure, possibility of obstructions, fever, history of polyps, nosebleeds, or any change in sense of smell?
Disrobing instructions: None Vital signs: All Other measurements: Weight Instruments and supplies: Nasal speculum, forceps, and gauze pads Possible procedures: Nasal smear and possible sinus films Possible lab procedures: Cultures from smears
Nutrition
Recent weight loss or weight gain, food likes or dislikes, depression or anxiety concerns?
Disrobing instructions: None Vital signs: All Other measurements: Height and weight Possible lab work: Related blood work continues
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TABLE 6-2 Common Screening Questions That Coincide with Specific Body Parts or Systems and Anticipatory Guidelines (continued) BODY PART OR SYSTEM
COMMON SCREENING QUESTIONS
ANTICIPATORY GUIDELINES*
Psychological
Depression, irritability, concentration problems, nervousness, mood changes, increase in stress, any changes in sleep pattern, alcohol or substance abuse, suicidal thoughts?
Disrobing instructions: None Vital signs: Blood pressure Other measurements: Weight Possible lab work: Blood work for related symptoms Comfort instructions: Be a good listener; have tissues accessible.
Respiratory
Shortness of breath, cough, phlegm, wheezing, coughing up blood? Any history of respiratory disease or frequent infections?
Disrobing instructions: Remove all clothing from the waist up. Vital signs: All Other measurements: Weight and spirometry (test that measures lung capacity) Possible equipment and supplies: Nebulizer (instrument used for breathing treatments), oxygen tank and supplies (for oxygen therapy), pulse oximeter (instrument used to measure oxygen saturation), and spirometer (instrument used to measure lung capacity) Possible procedures: Pulse oximetry, breathing treatments, oxygen therapy
Skin
Rashes: Location, itching, redness, or drainage? Any changes in laundry detergents, fabric softeners, body lotions, make-up, etc.? Cysts: Location? Moles: Location, any changes in shape, size or color? Warts: Location, recent viruses, or multiplication of warts? Hair: Loss of hair, excessive hair growth, or growth of hair in unusual locations? Nails: Changes in the nail?
Disrobing instructions: Remove clothing to expose affected areas. Vital signs: Temperature and blood pressure (do not place stethoscope or BP cuff directly over a rash or seeping area) Other measurements: Weight Possible equipment and supplies: For rashes: examination equipment and supplies including: Wood’s lamp (ultraviolet light) and magnification apparatus For cysts: I & D tray, anesthetic, syringe needle, and gauze For moles: Mole removal or excision tray, electrocautery unit, biopsy container, anesthetic, syringe, needle, and gauze For warts: Mechanical removal: Excision tray, anesthetic, syringe, needle, and gauze Chemical removal: Histofreeze unit or equivalent, anesthetic syringe, needle, gauze For hair: Wood’s lamp and magnification device For nails: Nail removal tray, anesthetic, syringe
Throat and neck
Hoarseness, difficulty in swallowing, history of goiter, tobacco use, or history of throat disease?
Disrobing instructions: Remove clothing from the waist up. Vital signs: All Other measurements: Weight Possible instruments and supplies: Penlight, possible head lamp, and a warmed laryngeal mirror for throat exams
Urinary
Pain upon urination, increase in urination, the need to urinate at night, the immediate need to urinate, is stream weak or unsteady, are you able to completely empty your bladder? Have you noticed a loss in force of your urine stream, any changes in urine volume, bedwetting, lower abdominal or lower back pain, fever, vaginal or penile symptoms? Any history of urinary disease?
Disrobing Instructions: Remove clothing from the waist down. Vital signs: All Other measurements: Weight Possible equipment or supplies: Sterile urine container and cleansing wipes to collect a clean catch urine specimen; pelvic tray if vaginal symptoms present; STD culture supplies for patients with vaginal or penile symptoms Possible lab procedures: A complete urinalysis and culture and sensitivity for urinary symptoms; STD testing for related symptoms
*Procedures and supplies will vary according to office policy. Some offices require a full set of vital signs to be performed on every patient. Never open any tray or perform any test until you receive an order to do so from the provider.
DEVELOPING IN-OFFICE SCREENING SKILLS
just to make certain that there have been no changes since the last visit. Patients are usually happy to share this information when they understand the reason for the questioning. Drug allergies should be written in red so that they stand out. Make certain that the patient understands the difference between a drug allergy and a side effect. Patients who experience nausea or diarrhea when taking specific medications may relate the symptoms to an allergic reaction. Ask the patient for a list of symptoms that occur when they take a specific drug. If the symptoms appear to be a side effect, the provider will need to develop this more with the patient to determine if the particular drug in question should be recorded as a drug allergy.
Documenting the Closing, or Professional, Signature The closing signature, also sometimes referred to as a professional signature, refers to the way that entries are signed on a progress note. The most complete method used to sign off a chart entry is to document first and last name followed by a credential. Some offices will just have employees document the first initial of the first name, and full last name, followed by their credential. Medical assistants should always check the office’s protocol to determine which method is correct for the particular office in which they work. DOCUMENTATION EXAMPLE: CHIEF COMPLAINT COMBINED WITH A BRIEF HPI
02-12-XX 1415
Chief Complaint: “I have a horrible headache” x 2 days. Pain rating 10+. “The pain starts in my forehead and radiates to the back of my head and neck.” –visual disturbances, +N/V, -aura, –Hx of migraines. Self Treatment: Pt. has taken three 1000 mg doses of acetaminophen over the past 2 days (“little relief”) Rx: Ortho Tri-Cyclen 28, and Paxil 30 mg daily. NKDA. Robin Spencer, RMA
DOCUMENTATION EXAMPLE: CHIEF COMPLAINT WITHOUT AHPI
02-12-XX 1415
Chief Complaint: “I have a horrible headache.” Robin Spencer, RMA
IMPROVING ANTICIPATION SKILLS AND FOLLOWING OFFICE PROTOCOL Many offices have general protocol guidelines that are to be followed when a patient comes in for a specific type of exam or when the patient presents with specific
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symptoms. Examples include putting a patient with chest pain into a trauma room or setting up a pelvic tray for patients with vaginal symptoms. A list of written orders called standing orders was once common in medical offices up until a few years ago. These orders were developed by the provider for procedures that were to be performed when the patient complained of specific symptoms. Today, the Center for Medicare and Medicaid Services (CMS) maintains that providers must show medical necessity for all procedures performed. This means that no procedure should be performed until the provider has had an opportunity to thoroughly examine the patient to determine if the test is medically necessary. Examples of previous standing orders included: performing a chemical urinalysis on all patients complaining of urinary symptoms, performing a rapid strep test on all patients with a sore throat, and performing a blood glucose level on all patients who are diabetics. The only exception now in which providers can implement standing orders is when global billing is in place. Global billing means that there is one set price for a series of visits and procedures. Examples of global billing include a one-price package for maternity or surgical patients. Any standard tests or procedures performed within the package, such as urine dips for all pregnant patients or dressing changes for postsurgical patients, have already been factored into the package. In these cases, the provider can institute standing orders because the insurance company is not being billed for each individual test or procedure.
TOOL BOX
C R I T I C A L T H I N K I NG CHALLENGE You are interviewing a 16-year-old female patient who is complaining of lower abdominal pain that radiates to her back side. The pain has been present for three days but seems to be worsening. The pain level is about a “6” on the pain scale, according to the patient. The patient also states that she has a “green vaginal discharge that smells really bad.” 1. How will you have the patient disrobe for the provider? 2. What tray might you set up just in case the provider wants to examine the patient more thoroughly?
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Even though standing orders for the most part are no longer acceptable, the medical assistant can still anticipate what the provider may order based on the patient’s chief complaint. It is fine to obtain a tray and collect supplies that coincide with the tray as long as nothing is opened until an order is received. It is also acceptable to retrieve the blood drawing tray and pull lab slips as long as the supplies are not used until the order is given. Medical assistants can save a great deal of time for all parties involved by being proactive.
TOOL BOX
CR ITI C A L TH I N K I N G C H AL LEN G E The front office receptionist calls back to your extension to tell you that a patient walked in off the street complaining of chest pain. The reception room is packed with patients that have scheduled appointments. 1. Should you take this patient straight back to the clinical area? If so, why? 2. What will you do if the patients from the reception area complain that this patient who didn’t even have an appointment was seen before them? 3. How should the patient be taken back to the exam or special procedures room? 4. What equipment should be available for this type of patient? 5. How quickly should the provider be notified? Should you start any procedures before the provider has had an opportunity to examine the patient? Why or why not?
THE PROVIDER’S ROLE DURING THE ASSESSMENT PROCESS The provider’s role during the assessment process includes the following: 1. Expanding on the HPI to include the exact location, quality, severity, duration, timing, context, modifying factors, and associated symptoms 2. Performing a review of systems 3. Performing an examination on the patient (Figure 6-5) and documenting the findings 4. Forming a diagnosis 5. Stating plans for testing, probable treatments, and education Once the examination is completed, the provider will order appropriate testing, procedures, treatments, and patient education based on the patient’s problem. The medical assistant should always be accessible at the conclusion of the visit to set up or perform the orders listed in the “Plans” section of the progress note.
FIGURE 6-5 The provider performs the physical assessment on the patient.
THE FOLLOW-UP APPOINTMENT/ PROGRESS NOTES Patients will often be asked to return for a single or series of follow-up appointments when diagnosed with
E M R A P P L I C AT I O N Many of the latest EMR programs have the ability to copy and paste information from previous progress notes into current progress notes. This feature is wonderful for those patients who suffer from chronic conditions. The user just clicks on what applies to this visit and copies and pastes the information onto the current prog-
ress note. EMR software programs also include standard templates that may be used for various types of exams. This entire process greatly reduces the amount of typing that the provider has to perform and allows the provider to spend more time with each patient.
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a new problem. It is especially important for the medical assistant to have good interviewing and listening skills during these types of screenings. A progress note is a follow-up note from a previous visit. This information elaborates on the patient’s progress between visits. The medical assistant may be responsible for listing any changes in the patient’s symptoms and for determining patient compliance in following home care instructions. A failure to follow home care instructions should be noted in the chart so that the provider can address the noncompliance with the patient. Documentation of the noncompliance may
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also be used in a court of law in the event that complications occur in the patient’s condition and the patient files a medical negligence claim against the provider. When patients are scheduled for follow-up appointments, the medical assistant should pull all lab, diagnostic, and consultation reports that were performed between the initial appointment and follow-up appointment. These reports should be attached to the front inside cover of the chart so that they are readily accessible for the provider. Table 6-3 lists items that should be documented in a progress note.
TABLE 6-3 Parts of the Progress Note PARTS OF THE PROGRESS NOTE
DESCRIPTION OR FACTS
1. Date and time
Check the policy of the office for the time and date system preferred.
2. Reason for the visit
Usually listed as a follow-up from the last visit.
3. Current symptoms
How does patient feel now? Which symptoms are better, and which symptoms are worse?
4. Patient’s compliance or noncompliance to follow home care instructions
Did the patient take the medicine as prescribed? Did the patient follow bandaging instructions? Did the patient follow up with the consultant (for legal purposes)?
5. Physical observations made during the follow-up visit
These are objective observations that the provider may not see, such as the condition of the bandage when it was first removed from the patient’s wound. May be recorded or verbally reported to the provider.
6. Closing signature
First name, last name, and credential.
DOCUMENTATION EXAMPLE: PROGRESS NOTE
Pt. here to have sutures removed today following last week’s appointment. Bandage removed. Dressing was clean and dry. Pt. states that she has had little pain and that she took all of her antibiotic and followed all home care instructions. Erin Speck, CMA (AAMA)
E M R A P P L I C AT I O N When using electronic charts, ensure that all lab results, consultation reports, and diagnostic reports are electronically downloaded or scanned into the patient’s electronic chart prior to the provider’s examination. If it is not pos-
sible to download or scan the report prior to the exam, you may attach a paper report to a clipboard with a message to the provider that the information will be scanned into the chart at a later time.
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09-14-XX 1200
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PROCEDURE 6-1 Conduct and Record Results from an In-Office Screening Objective: To conduct an in-office screening and properly document the findings from the screening within the patient’s medical record.
Equipment/Supplies: ❖ Patient’s chart ❖ Black pen ❖ Gowns/drapes
❖ Any equipment and supplies necessary to set up the room and the patient
PROCEDURE STEPS
RATIONALE
1. Check the appointment schedule to determine the purpose of the patient’s visit and gather the appropriate supplies.
Gathering the appropriate supplies prior to escorting the patient back to the room will help to save time once the screening has begun.
2. Greet the patient in a professional manner and escort to the examination room.
Greet the patient with a smile. It helps to lift the patient’s mood and sets the tone for the remainder of the visit. Offer assistance to elderly or physically handicapped patients.
3. Identify yourself and state your title.
It is common courtesy to tell the patient your name. Patients like to put a name with a face. Stating your title shows that you have authority to execute the procedures that you will be performing.
4. Identify the patient by using two different identifiers.
It is important to make certain that you have the correct patient and correct chart. Not having the correct chart can create major administrative problems with billing and put the patient at risk for erroneous care and treatment.
5. Seat the patient so that the patient is comfortable and can easily see your face.
Some patients feel uncomfortable sitting on the exam table during the initial screening. Question the patient to see where he prefers to sit during the initial screening.
6. Demonstrate a caring attitude as you ask the patient to explain the reason for the visit. (See Figure 6-6.)
A caring attitude will help to build trust between you and the patient.
FIGURE 6-6 The medical assistant demonstrates a caring attitude as she obtains information for the chief complaint.
7. Briefly expound on the HPI (optional).
Remember that in some offices the provider will want you to ask enough questions to anticipate care but will not have you record your findings because the provider must develop the HPI for reimbursement purposes.
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PROCEDURE STEPS
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RATIONALE
8. Provide or update the patient’s medication information.
Many patients see multiple providers. It is important to update the patient’s medication list so that the provider doesn’t prescribe a medication that negatively interacts with another medication already being taken by the patient.
9. Update the patient’s drug allergy status.
Patients can develop drug allergies at any time. They may forget to mention this on their own, so the medical assistant should bring up the topic to make certain that there have not been any changes since the last visit.
10. Properly document the information on the progress note. 11. Sign off the chief complaint by listing an approved closing signature or your professional signature.
This may vary from one office to the next, but usually consists of your first and last name followed by your credential.
12. Set up the room and any trays according to the patient’s complaint (Figure 6-7).
Using critical thinking skills based on your in-office screening will help you determine what items will be necessary during the exam.
FIGURE 6-7 After writing the chief complaint, the medical assistant sets up a tray that coincides with the patient’s symptoms.
13. Have the patient disrobe according to the symptoms. 14. Dismiss yourself in a professional manner and give the patient an indication of how long the wait will be.
This is just a common courtesy gesture.
15. Notify provider, or have someone else notify the provider, if you suspect that the patient’s symptoms warrant immediate assessment.
Providers should be alerted as soon as possible when patients are exhibiting symptoms that could be considered life-threatening.
DOCUMENTATION EXAMPLE: CHIEF COMPLAINT WITH HPI
10-10-XX 1400
Pt. c/o L. ear pain (8) x 3 days. Pain intensifies while lying down. Heating pad makes symptoms feel better. –dizziness, –sore throat or sinus drainage. OTC: Ibuprofen 500 mg, every 6 hours (little to no relief). –Other OTCs, –Rx, –Drug Allergies. Ulisha Thompson, CMA (AAMA)
DOCUMENTATION EXAMPLE: CHIEF COMPLAINT (ONLY)
10-10-XX 1400
Pt. c/o L. ear pain. Ulisha Thompson, CMA (AAMA)
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PROCEDURE 6-2 Conduct a Follow-Up Interview and Develop a Progress Note Objective: To develop a progress note that illustrates the nature of the visit and the compliance of the patient to follow home care instructions.
Equipment/Supplies: ❖ Patient’s chart ❖ Black pen ❖ Gowns/drapes
❖ Any equipment and supplies necessary to set up the room and the patient
PROCEDURE STEPS
RATIONALE
1. Identify the patient and verify that you have the correct chart by asking the patient for date of birth. Compare what the patient states with what is recorded in the chart.
It is important to make certain that you have the correct patient and correct chart. Not having the correct chart can create major administrative problems with billing and put the patient at risk for erroneous care and treatment.
2. Position yourself directly across from the patient.
Sitting at the same level as the patient helps to put the patient at ease.
3. Ask the patient how they are feeling. Are symptoms better or worse?
It is important to establish whether the patient feels she is getting better or not; this will help determine if the treatment is successful.
4. Inquire about compliance issues. (The provider may prefer to conduct this part of the screening.)
It is important to determine if the patient is following the correct home care instructions. Failure to follow home care instructions could result in a delay of improvement. This is also an important question for potential legal problems down the road.
5. Take the time to make any observations that the provider will not have an opportunity for, such as the way the patient’s bandage looks prior to and following removal (Figure 6-8).
If the provider does not have an opportunity to see or hear something that the medical assistant hears or sees, it should be documented to alert the provider so that the provider can address the issue with the patient.
FIGURE 6-8 Observing the bandage before and after removal helps determine if the patient followed home care instructions.
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PROCEDURE STEPS
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RATIONALE
6. Document findings from the follow-up interview onto the patient’s progress note. Record the following: the date and time of the visit, the reason for the visit, current symptoms (if any), and any information that confirms or denies the patient’s compliance to follow home care instructions. Sign off the chart using the proper closing signature.
You do not have to document current medications since the patient was just in.
7. Give the patient proper disrobing instructions.
This will save time for both the patient and provider.
8. Dismiss yourself in a professional manner and give the patient an indication of how long the wait will be.
This is a common courtesy measure.
9. Pull all lab and diagnostic lab work between the previous appointment and the follow-up appointment and attach them to the inside front cover of the chart (Figure 6-9).
This saves time for the provider.
FIGURE 6-9 The medical assistant attaches all labs that were performed between the prior visit and today’s visit to the inside front cover of the chart.
DOCUMENTATION EXAMPLE:
03-14-XX 0815
Pt. is here to have urine rechecked following last week’s appt. Pt. denies any current symptoms and states the following: “I took all of my antibiotics except for the last six tablets. The medicine made my stomach feel queasy so I just stopped taking it.” No other reactions to the med other than queasiness. Patricia Holt, CMA (AAMA)
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4. Which of the following does not need to be recorded when documenting a follow-up visit? a. The date of the follow-up visit b. The patient’s current medications c. The patient’s compliance or noncompliance to follow home care instructions d. The reason for the visit 5. Who is responsible for developing the HPI? a. The provider b. The medical assistant c. Mainly the provider, but the medical assistant should ask enough questions to determine how to set up the patient and the room d. None of the above
Web Activities 1. Type the following phrase into a search engine: “guidelines for documenting in a patient’s chart.” Select two articles that coincide with the information in this chapter. Record any similarities and differences between the articles and chapter content. 2. Type the following phrase into a search engine: “2008 Joint Commission National Patient Safety Goals (NPSG).” These goals not only discourage the use of particular medical abbreviations but also list other measures that should be taken to improve patient safety. List at least three safety measures that should be instituted in a hospital or medical setting to prevent or minimize errors.
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CONNECTION Using your StudyWARE CD-ROM: ❖ Complete the Flash Cards activity for this chapter. ❖ Complete the Quiz for this chapter in Test Mode.
THE DVD LINK On your StudyWARE CD-ROM, go to the DVD Challenge for this chapter. View the DVD clip and respond to the following questions: 1. In the first scenario, Keisha obtained the patient’s chief complaint and also developed the HPI. Do medical assistants always develop the HPI when taking a patient’s chief complaint? Even if it is not the medical assistant’s role to record the HPI, what HPI information would be helpful in determining how to prep the patient and set up the examination room? Keisha did obtain a urine sample just in case the patient had a UTI. Should she run any testing on the urine before the physician examines the patient? 2. In the second scenario, Shanna asked few essential questions to help her anticipate how the patient should disrobe and what trays may need to be set up. Additionally, she told the patient that she thought she probably had the flu. Why do you think that the physician was so upset with Shanna? Do you feel that the physician was wrong to reprimand Shanna?
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Chapter Summary The medical assistant has many responsibilities during in-office screenings. Knowing what questions to ask will help identify what type of exam the provider may need to perform and what testing may be ordered as a result of the patient’s symptoms. Identifying this information ahead of time will help the medical assistant know how to prepare the patient for the exam and what equipment and supplies may be needed prior to, during, or following the exam, saving both the provider and patient a great deal of time. The medical assistant will be responsible for documenting findings such as the patient’s chief complaint and vital signs during the initial screening. The medical assistant may also be responsible for updating the patient’s medication list and drug allergy status. Whether or not the medical assistant will document any of the HPI will vary from office to office, but in most practices the provider will document this information. The medical assistant must be cognizant of boundaries when performing screening duties and not inadvertently or intentionally suggest to the patient the diagnosis or treatment. The medical assistant must also stay within boundaries when anticipating what equipment and supplies may be necessary and what tests may be ordered. It is acceptable to gather equipment and forms in the event that the provider performs a specific exam or orders a certain procedure, but the medical assistant should never open supplies, or perform any testing without a direct order from the provider.
FIELD APPLICATION CHALLENGE A patient comes into your office with abdominal pain. You ask the patient to give the location of the pain, rate the pain, and tell you how long the symptoms have been present. You don’t ask any more questions and you have the patient disrobe from waist up. The provider enters the room and develops the complaint. Upon expounding on the complaint, the provider finds that the patient has urogenital symptoms in conjunction with the abdominal pain. Answer the following questions based on the above scenario:
1. What mistakes did you make during the interviewing process? 2. Why should you perform a brief HPI, even through you may not be responsible for documenting the information? 3. What tray or supplies should you set up based on the provider’s findings? 4. Did you have the patient disrobe appropriately? If not, how should you have had the patient disrobe?
Chapter Assessment 1. What question would not be necessary when screening a patient with chest pain? a. Does the pain radiate to any other part of your body? b. Are you experiencing any shortness of breath? c. Do you have any dyspnea? d. Are you experiencing any nausea or vomiting? 2. What is the job of the medical assistant during in-office screenings? a. To gather the patient’s chief complaint b. To perform vital signs c. To diagnose the patient d. Both a and b
3. Which of the following may not be performed by the medical assistant without an order from the provider? a. Perform a blood glucose on the patient b. Set up a pelvic tray for a patient experiencing vaginal symptoms c. Have the patient disrobe from the waist down for anal symptoms d. Give a nauseated patient an emesis basin
C H A P T E R
Conducting Telephone Screenings Chapter Outline Customer Service and Telecommunications Basic Rules of Etiquette Triaging Telephone Medicine Telephone Screenings Legalities of Telephone Medicine Desired Traits of a Good Telephone Screener The Medical Assistant’s Role during Telephone Screenings Summary of Dos for Patient Screenings
Screening Patient Test Results Handling Critical Lab Results Calling Patients with Test Results Calling in Prescriptions Sending Faxes Electronic Mail (E-Mail) Working with TDD or TTY Devices Scheduling Appointments for Patients with Limited English Video Conferencing
7 Essential Terms algorithm appointment grid critical lab value emergency medical services (EMS) panic lab value telecommunications telecommunications device for the deaf (TDD) telephone screener telephone triage teletypewriter (TTY) triaging
CONDUCTING TELEPHONE SCREENINGS
KEY COMPETENCIES
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CAAHEP
ABHES
Performing a Telephone Screening
III.C.3.c.4.a
VI.A.1.a.4.ff
Screening and Following Up on Test Results
III.C.3.c.4.i
VI.A.1.a.4.l
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Developmental Objectives After completing this chapter, you should be able to: 1. Correctly spell and define the essential terms. 2. Explain why customer service is so important when communicating with patients via telecommunications equipment. 3. Give four examples of different types of telecommunications devices. 4. Contrast the differences between telephone triage and telephone screenings. 5. List three different screening tools that can be used to screen patient phone calls. 6. List factors that must be considered when performing procedures via telecommunications. 7. List four components that should be included in a telephone screening training program. 8. List the desired traits of a telephone screener and three steps that should take place before the screening process begins. 9. List four different actions that are typically found in a telephone screening manual. 10. List several different types of life-threatening emergencies and explain two normal actions that are given to patients with life-threatening emergencies. 11. Describe the medical assistant’s role in screening and calling patients with test results. 12. Explain how HIPAA laws impact both telephone screenings and telephone calls to patients about test results. 13. Explain the importance of critical or panic lab values. 14. Describe the following terms and explain how these types of telecommunications devices are used to communicate with patients and other medical entities: TDD machines, fax machines, videoconferencing equipment, and e-mail.
Introduction Telecommunications is a method of communication that allows the participants to communicate at a distance. It works by sending electromagnetic signals between such devices as the telephone, television, radio, and computer modem. For many years the telephone was the primary form of telecommunications and the most common way that medical offices communicated with patients outside
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the office. The latest technological advances now allow medical office personnel to communicate with patients through other forms of telecommunications including faxes, personal digital assistants (PDAs), teletypewriters (TTYs), and computers. Telecommunications procedures are performed by both the administrative and clinical staff. The clinical medical assistant uses telecommunications equipment to screen patient problems, relay prescriptions, talk with other health care entities, and relay information to the patient regarding test results and changes in medication. The type of telecommunications equipment used to communicate with patients and other health care facilities varies according to what equipment is available to both the sender and receiver. It is important for clinical medical assistants to familiarize themselves with the various forms of telecommunications devices and to understand the legal implications that are associated with using this technology for sending and receiving protected health information (PHI). It is also important for medical assistants to know the boundaries when screening patients via telecommunications technology. This chapter will provide the medical assisting student with important information in these areas and many more.
CUSTOMER SERVICE AND TELECOMMUNICATIONS The telephone has always been considered the lifeline of the medical office. Although this is still true to a
degree, all forms of telecommunications are now vital. Technology is quickly changing the way that we communicate with our patients. Whether over the phone or via the computer, good customer service is essential to attract and keep patients. In the past, patients remained with one provider throughout the majority of their lives, but today, most patients will seek the services of several providers during their life span. This is largely due to the accessibility of providers and the multitudes of specialists in today’s health care environment. Furthermore, employers constantly look for more economical health care solutions to reduce the company’s expenses. Sometimes this forces the patients to change providers whether they want to or not. As a result, patients compare their experiences from one medical office to the next and have higher expectations than they did in years past. Patients gauge much of how they feel about the provider based on how they are treated by the staff members associated with the practice. The medical assistant must make every effort to accommodate patients and to make their experience with the office satisfying. Even though it is important to treat the patient well while they are in the office, it is just as important to treat the patient with a caring attitude when communicating with the patient over the telephone or computer (Figure 7-1). Studies confirm that more patients leave their providers based on their experiences outside the office than they do based on their experiences inside the office. Patients become frustrated because office employees never return their phone calls or are rude when they speak to them over the phone.
At times, it may be difficult to understand patients with limited English-language skills. This is especially true when speaking to limited English patients over the telephone. Medical assistants should listen attentively and not allow themselves to become distracted while talking on the phone. The patient may also have a difficult time understanding the medical assistant, which is why it is so important to speak clearly and distinctly when communicating over the phone. However, don’t shout; the patient is not deaf, and shouting may make the patient feel
more anxious. If communications are ineffective, the medical assistant should ask if there is anyone available to act as an interpreter during the phone call. Additionally, interpreting companies offer interpreting services over the phone. The medical office should keep a list of businesses that perform these kinds of services and share the information with patients. The patient or the medical assistant can call the interpreting company and arrange a three-way conference call, although there is usually a charge for this type of service.
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7. Try to answer the patient’s question during the call if at all possible as long as it is within your scope of duty. If it is not possible for you to answer a question, give the patient a timeline when they can expect a call back. 8. Follow through with promises made to perform certain tasks such as obtaining lab results, calling in a prescription, or having the provider call the patient back. If there is a reason why you cannot perform the task in a timely fashion, give the patient the courtesy of a follow-up telephone call. Inform the patient that you are working on the task and that you will get back with him just as soon as you have an answer. 9. Always allow the patient to hang up first. Some basic rules to remember when communicating with patients through e-mail include:
FIGURE 7-1 The medical assistant needs to show compassion and concern over the phone as well as in person.
Basic Rules of Etiquette The clinical medical assistant does not typically answer the telephone; however, he may have several calls transferred to his personal extension or have several messages forwarded to his corporate e-mail account. Remember basic manners and rules of etiquette when communicating with patients through telecommunications equipment. The following are rules to keep in mind when communicating with patients over the telephone: 1. Check your attitude before answering the phone or placing a call. You must strive to be professional and pleasant even if you don’t particularly feel like it. 2. Always identify yourself and your title at the beginning of each call. 3. Avoid getting upset when a patient is rude or obnoxious. 4. Try to diffuse a patient’s anger by letting him know that you want to help get the problem resolved. 5. Show interest in what the patient has to say. 6. Do not interrupt the patient when the patient is talking.
1. Respond to all patient queries and answer them in a timely manner. 2. If you do not have an immediate answer to the patient’s e-mail, send an e-mail back to the patient explaining that you have some research to do and will respond just as soon as you have an answer. 3. Do not use all uppercase letters when communicating with patients through e-mail. It may appear that you are shouting at them. 4. Encourage the patient to send additional e-mails or to call the office with any additional questions. 5. Include a salutation and a complimentary closing and type your name and credential when sending patient e-mails. 6. When you are going to be out of the office for a period of time, prepare a custom-automated response explaining that you are going to be out of the office and when you expect to return to the office (Figure 7-2).
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P A T I E N T P E R S P E CT IV E It is quite frustrating when I have to call the physician’s office several times before anyone will call me back. I hate to say it, but I have changed providers based solely on my experiences with staff members, even though I loved the physician.
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Both Dr. Wong and I will be on vacation the week of June 10. We will return on June 17. If you have an urgent need, please call the office number at 123–456–7890. Dr. Saunders (Dr Wong’s associate), will be covering for Dr. Wong while he is gone. The name of Dr. Wong’s medical assistant is Amy Tucker. If your need is not urgent, I will e–mail you with a response the week I return. Kerri Jones, CMA (AAMA) Douglasville Medicine Associates Douglasville, NY 01234 (123) 456–7890
FIGURE 7-3 This medical assistant is monitoring her telephone attitude by looking into the mirror as she speaks to the patient.
FIGURE 7-2 The screen shows common message that can be displayed when the medical assistant is going to be away from the office for a period of time.
arrive at their preferred provider’s office with lifethreatening emergencies. During these episodes, the provider is usually accessible and will assist the office staff with triaging responsibilities. Good communication and customer service skills are essential when working with patients, especially over the phone. Remember, you have to work harder to convey a pleasant attitude when the patient cannot see your face or read your body language. Patients may, however, be able to discern your attitude through your tone of voice. They may even be able to distinguish whether you are frowning or smiling. A technique to help you remember to smile is to place a mirror in front of the telephone (Figure 7-3). Observe your expressions as you speak to the patient. If you catch yourself frowning, immediately change your frown to a smile.
TRIAGING Hospitals, especially emergency departments, practice a technique known as triaging or sorting patients according to the extent of their injuries or illnesses. Patients who have life-threatening illnesses or injuries are seen before patients with milder symptoms. Skilled nurses and medics who have special triage training are usually employed by hospitals to perform this important task. In-office triage is not as common as hospital triage but may need to be performed in ambulatory care centers such as urgent care centers. Occasionally, patients
TELEPHONE MEDICINE Another form of triage is telephone triage. Triaging over the phone is similar to triaging in person. The person performing the triage listens to the patient’s symptoms and determines what action to take as a result. Patients who have life-threatening symptoms are usually instructed to hang up and dial 911. Patients with nonlife-threatening illnesses, such as the flu or poison ivy, may be given home care instructions or be scheduled for an appointment. Even though the person performing the triage may follow specific protocol, he may occasionally use some of his own assessment skills to determine how to handle patients whose symptoms do not coincide with protocol manuals. Some triagers work in facilities such as patient call centers where the provider is not present. Telephone triage is controversial because of the responsibilities that are taken on by the employee conducting the phone call. Many legalists believe that triaging places the triager in the role of practicing medicine. The person conducting the triage may ask the patient a series of questions that leads him to believe that the patient has a particular disease or disorder. This may be interpreted as diagnosing. For example, if
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a patient’s mother calls complaining of lesions on her son’s torso, the person conducting the call may ask a series of questions that lead the triager to believe that the child has chicken pox. If the triager makes a statement such as, “It sounds as though your son may have chicken pox,” it may be construed as diagnosing. If the triager goes on to state what the mother can do to help ease the son’s symptoms, this may be interpreted as prescribing. Medical assistants must be careful to never put themselves into a role of diagnosing or prescribing. If the medical assistant is going to handle sick calls from patients, he should take on the role of a “screener.”
Telephone Screenings A telephone screener is specially trained to use a telephone screening manual that lists conditions typically associated with the practice in which the screener works. Each problem has a short series of questions that should be asked when patients call complaining of particular symptoms. A screening manual usually has limited options, most of which direct the screener to offer the patient an appointment within a certain period of time based on the seriousness of the disorder. If the patient’s responses match up to those beside emergency medical services (EMS), the patient is directed to call the EMS. The questions and responses assist the screener in determining the seriousness of the symptoms and in which order patients should be scheduled. Manuals may be set up as a screening grid (Figure 7-4) or algorithm (decision tree), both of which include step-by-step protocol that states an action that should be taken based on the patient’s response. The decision making is taken out of the hands of the professional handling the call and placed with the party or parties that designed or approved the manual. When a patient’s symptoms do not match those exactly as listed in the screening manual, the person conducting the screening should transfer the call to a qualified provider. Screeners should never offer any type of home care advice unless they have first been approved by the provider. Another tool that is used in some practices is an appointment grid (Figure 7-5). An appointment grid lists specific symptoms under a list of appointment actions. In this scenario, the screener does not ask a series of questions, but rather looks at where the patient’s complaint falls within the appointment grid. If the patient’s complaint falls under the “Same Day” heading, the screener offers the patient an appointment for that same day. There is little screening performed with this type of system.
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E M R A P P L I C AT I O N Many of the newer EMR programs contain a telephone screening component. The medical assistant starts by scrolling down a list of common conditions and clicks on the condition that best matches the patient’s major complaint. The screener then scrolls through a list of related symptoms and places a check in any of the boxes that match the patient’s symptoms. At the end of the screening, the program will list instructions that are to be given to the patient and automatically records the information within the patient’s EMR. This type of software saves a great deal of time in both conducting and in documenting the call.
FIGURE 7-4 A sample of a telephone screening grid that is used for patient screenings NOSEBLEEDS Task or Question
Response
Action
Yes
EMS
Yes 4. Has patient lost consciousness or appear to be confused or having difficulty seeing, speaking, or walking?
EMS
Yes
EMS
1. Record today’s date and time of call or visit. 2. Give a brief description of the patient’s complaint, using the patient’s own words. 3. Note time of onset. If > 30 minutes and nose is still bleeding profusely.
5. Does patient have a history of hypertension and is the nose bleeding profusely? 6. Is patient on blood thinners?
ASAP
If patient has been applying pressure to nostrils and leaning forward, does nose continue to bleed after 10 minutes? 7. Is nosebleed the result of a traumatic injury?
Yes
ASAP
8. Does patient have reoccuring nosebleeds?
Yes
DC
9. If nosebleed is mild to moderate and patient has not answered a question that required a response.
Yes
DC
10. List all OTC and prescribed medications that are currently being taken by the patient. 11. List any drug allergies. 12. What has the patient done to control the bleeding? Has the bleeding subsided? 13. List instructions given to patient and state from where the information came. 14. Record exit signature.
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CALL EMS
FIGURE 7-5 An appointment grid allows the patient’s symptoms to be matched up to an action. This helps to determine when to schedule the patient for an appointment.
IMMEDIATE ASSESSMENT BY DR.
Any life-threatening injuries • Severe trauma Any life-threatening illnesses • Chest pain
Painful, swollen leg
Anaphylactic reactions
BP > 180/110
Asthma (severe attacks)
Hemoptysis (coughing up blood)
Breathing difficulties Burns that are severe Hemorrhaging Poisonous substance ingestion (have patient call poison control in mild situations) 1st time seizures and convulsions
Hematemesis (vomiting blood) Bloody stools Severe abdominal pain Syncope (conscious now)
Shock Unconsciousness Strokes
Fever > 102.5 Mental status changes If very ill (patient is lethargic or irritable) Extremely anxious or acutely depressed patient
Suicide attempt
Severe headache
Blood sugar < 60 or > 250
Telephone triage manuals may be used by the medical assistant, but the medical assistant must be careful about giving instructions that stray from those listed in the manual. The screener should double check with the provider prior to giving the patient home care instructions appearing in the triage manual.
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CR ITI C A L TH I N K I N G C H AL LEN G E For each of the following responses, write T for triage responses and S for screening responses. Write TS if the response applies to both. ____ Let me transfer you to the physician. ____ Based on your description, it sounds as though you may have shingles. I am going to set you up an appointment for tomorrow. ____ To be on the safe side, let’s have you evaluated by the emergency medical services. ____ I can schedule you for an appointment tomorrow at 10:00 a.m. ____ You might try putting some ice on the ankle and giving us a call later today to report how you are doing.
SAME DAY Within 8 hours Acute illnesses or acute exacerbation of chronic illnesses UTI symptoms–if possible schedule an appointment, if not schedule patient for lab appointment to bring in a urine sample Abdominal pain
WITHIN 1-2 WEEKS
Routine check-ups Follow-up exams
Chronic behavioral or emotional problems
URI symptoms, cough, sore throat, congestion, and ear pain Fever Diarrhea/vomiting Dizziness Headache
Acute wound or injury (cut, burn, sprain, fall, etc.) Rash Wound infection
Table 7-1 lists similarities and differences between the functions and qualifications of a telephone screener versus those of a triager.
Legalities of Telephone Medicine Medical assistants must stay within the boundaries of medical assisting during in-office procedures and when assisting patients over the phone or other telecommunications devices. This is especially important when conducting telephone screenings and calling in prescriptions. Table 7-2 lists factors to consider when performing telecommunications tasks.
Risk Management Guidelines to Minimize Liability Issues An effective telephone screening program should contain certain components, which include: 1. Comprehensive job descriptions stating which employees have the authority to handle these calls. 2. Protocol manuals with comprehensive instructions on proper procedures to follow when screening phone calls. Manuals should include questions that should be asked when the patient complains of a specific problem and actions that should be taken as a result of the patient’s symptoms. The manuals should also state when a provider should be consulted. 3. A structured training program that trains the screener how to properly screen calls and use the screening tools available in the office.
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TABLE 7-1 The Duties of a Telephone Screener versus a Triager TELEPHONE SCREENER
TRIAGER
Usually someone that is not licensed to practice medicine. May be the medical assistant or telephone operator.
Usually has some form of medical licensing. It is best if the person performing the triage is a provider, but may also be a nurse.
Should receive specialized training specific to each office.
Should receive specialized training specific to each office or call center.
Can usually offer an appointment or instruct patients to call the EMS.
Can offer appointments and instruct patients to call the EMS.
Should follow an approved telephone screening manual.
Should follow an approved triage manual.
A provider must be on the premises to handle calls that the telephone screener cannot.
The provider isn’t necessarily in the same location as the triager. The triaging may take place at a call center, which may be at a totally different location than the provider.
Should transfer calls to a provider when the patient has symptoms that do not follow the screening manual.
Usually makes his own decision on how to handle calls that do not follow a triage manual based on his training and experience.
Cannot offer home care advice unless authorized by the provider.
May offer home care advice based on protocol and experience.
TABLE 7-2 Factors to Consider When Performing Telecommunications Tasks
STATE REGULATIONS AND FEDERAL GUIDELINES Is there anything in the state or federal regulations that would prohibit the medical assistant from being able to perform the task, such as calling in particular types of prescriptions? What federal guidelines must be adhered to when using telecommunications technology (HIPAA rules)?
PROTOCOL TOOLS AVAILABLE FOR SCREENING PATIENTS OVER THE TELEPHONE OR VIA THE COMPUTER Whether screening over the phone or computer, the medical assistant should always use a screening manual or computer program that lists specific protocol that should be followed when the patient complains of specific symptoms.
4. A method of measurement. There should be a way to measure the trainee’s ability to handle the task of telephone screenings. Measurement should be performed during the training program, at the conclusion of the program, and throughout employment, if screening continues to be a part of the employee’s job description.
REINFORCEMENT PERSONNEL AVAILABLE The provider or another qualified individual should be on the premises and available to take over in those instances that the patient’s symptoms are beyond what the medical assistant can handle.
Desired Traits of a Good Telephone Screener Not every medical assistant is considered a good candidate for the role of a telephone screener. Telephone screeners should have wonderful listening skills, exemplary documentation skills, and the ability to stay calm in the midst of an emergency. Screeners must also
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S I T E C H EC K
H I PA A PAT R O L
As an insurance site reviewer, I check to see if there is some type of program in place to adequately screen patient calls. I look at the qualifications of the personnel performing the screenings and review the screening and protocol manuals used. If a nonlicensed person is giving out advice without following an approved screening manual, it may result in infractions to the practice.
The privacy rule permits disclosure to family members and friends when medical information directly pertains to the person’s involvement with the patient or patient’s care.
admit when the call is beyond their scope of duty and be willing to transfer the call to someone who is more qualified.
The Medical Assistant’s Role during Telephone Screenings Before the screening process begins, medical assistants should perform the following steps: Step 1: Identify themselves and state their credentials: Medical assistants should always start the call out by identifying themselves and stating their credentials. The medical assistant should never allow the office operator to identify them as the provider’s nurse. Step 2: Identify the caller and determine if the call is an emergency: The medical assistant should identify the caller and ask if the call is an emergency. If the call does not appear to be an emergency, place the patient on hold and pull the patient’s chart. (If the call does appear to be an emergency, the medical assistant should proceed to Step 3).
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E M R A P P L I C AT I O N When working in offices that have electronic medical records, you never have to pull the chart, you simply type the patient’s name into the computer and the patient’s record electronically appears on the computer screen. This feature is especially convenient during emergency phone calls.
If the caller is not the patient, the medical assistant should determine if there is any way that he may speak directly to the patient (coherent adult). If the patient is in great physical distress or is mentally incapable of effective communication, the medical assistant may address the patient’s current symptoms with the caller. The medical assistant should avoid any discussion other than what pertains to the current concern. Step 3: Identify the problem and obtain the screening or protocol manual: The medical assistant should listen to the patient’s complaint and refer to the screening manual for instructions on how to proceed with the call. Due to the seriousness of the task, medical assistants should never stray from the protocol or screening manual unless ordered to do so by the provider. When a patient complains of problems that are not listed in the manual, or the patient’s symptoms or history do not follow the symptoms listed on the complaint page, the medical assistant should stop immediately and seek guidance from the provider.
Using a Telephone Screening Manual Screening tables or algorithms have a list of questions or symptoms that should be asked about under certain conditions. If the patient responds to a question by saying No, the screener should continue the questioning until the patient answers with a Yes response. The screener then gives the instructions listed in the action column to the patient. Most books are set up so that questions and responses go from most severe to least severe (Figure 7-6) so when a patient answers with a Yes response, there is no need to proceed any further. Typical actions or instructions given to the patient include: 1. Contact the EMS, which is a service providing prehospital care to patients that are acutely ill or who have life-threatening injuries or illnesses.
CONDUCTING TELEPHONE SCREENINGS
INSECT BITES OR STINGS Task or Question
Response
Action
4. Is the patient having any problems breathing, is there swelling around the eyes, in the throat, tongue, or lip area? Does patient feel lightheaded or have a rash that is widespread?
Yes
EMS
5. Is the patient allergic to what bit or stung them?
Yes
EMS
Yes
Read and follow directions with EpiPen
6. Did the patient see what bit or stung them? Was patient bitten by anything that could be considered poisonous such as a scorpion or black widow?
Yes
ASAP
7. Is stinger still inside patient?
Yes
HC
8. Does patient have swelling and redness in the local area?
Yes
DC
1. Record today’s date and time of visit or call. 2. Give a brief description of the patient’s complaint using the patient’s own words. 3. Record date or time of onset.
If yes, does patient have an EpiPen?
If bite or sting occurred > 24 hrs ago and swelling or redness is not subsiding or getting worse.
DC Yes
ASAP
Does patient have a fever, rash, or enlarged glands and Yes bite or sting occurred >24 hours ago?
ASAP
Yes
ASAP
Yes
HC
9. Does patient feel sick or apprehensive in conjunction with the sting or bite?
Does area look infected? (red streaks, purulent discharge, etc.) 10. Was patient bitten by a tick? 11. List all OTCs and prescribed medications currently being taken by the patient. 12. Does patient have any known drug allergies? 13. List any instructions given to the patient and note from where they came. 14. Record exit signature.
FIGURE 7-6 The medical assistant does not need to proceed any further once the patient answers Yes. Here, the medical assistant instructs the patient to call the EMS.
2. Schedule a same-day appointment for patients with acute symptoms. 3. Schedule the patient within 24 to 48 hours for chronic conditions or less serious symptoms. 4. Give the patient a list of home care instructions, only after checking with the provider first.
Responding to Telephone Emergencies When the screener speaks to a patient or the family member of a patient who describes symptoms that may be life-threatening, the medical assistant’s first responsibility is to remain calm. If it is the policy of the office for the medical assistant to give instructions
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during life-threatening emergencies, then the medical assistant should follow the exact instructions listed in the screening manual. When the instructions on the screening page state that the EMS should be summoned, the medical assistant should calmly encourage the patient or representative of the patient to hang up and call the EMS without promoting panic (for example, “Mrs. Jones, it is probably best to have the emergency medical services come out and perform an evaluation on your husband, just to be on the safe side.”). This type of statement promotes an action without instilling fear. If the patient is alone, it may be best for the medical assistant to remain on the line with the patient while he directs another medical assistant to contact the EMS. The first medical assistant should hand the chart or message slip to the second medical assistant. The progress note or message should list the patient’s name, address, symptoms, and what the patient has done for the symptoms thus far. The second medical assistant should share this information with the EMS operator. Having the initial medical assistant remain on the phone with the patient will help the patient to remain calm. If there are family members or friends with the patient, instruct one of them to call the EMS. The EMS usually prefers that the call come from the residence where the emergency is occurring, if at all possible. If the medical assistant is to direct all emergency calls to the provider, he should immediately alert the provider, even if it means interrupting a phone call or an examination. If the medical assistant has not had time to pull the chart, he should either retrieve the chart himself or have someone else retrieve the chart so that the provider can refer to it as he speaks to the patient. Conditions Considered Life-Threatening Table 7-3 lists common types of emergencies and their symptoms. Medical assistants should follow the protocol of their office when handling emergencies. Most offices will have the medical assistant instruct the patient to call the EMS during possible life-threatening emergencies or will have someone else call the EMS while the patient remains on the phone. When the Patient Will Not Follow Emergency Instructions Occasionally, a patient will refuse the services of the EMS stating that he will have someone drive him to the hospital. When this occurs, it is important for the medical assistant to explain why the EMS should be summoned and state the possible consequences of not contacting the EMS. If the patient still refuses, the
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TABLE 7-3 Types of Life-Threatening Emergencies and Their Symptoms TYPE OF EMERGENCY
COMMON SYMPTOMS
Anaphylaxis: A severe allergic reaction to a food, medication, insects, or other environmental factor such as pollen
Swelling (lips, tongue, or throat), dizziness, mental confusion, respiratory difficulties, paleness or abdominal cramping may also be present
Breathing difficulties: Asthma, emphysema, COPD, and possible allergic reactions
Wheezing, severe coughing, inability to take in a deep breath
Chest pain (heart attack)
Chest pain or pressure. May radiate to the arms, especially the left arm, jaw, or neck. May be associated with nausea and vomiting, diaphoresis, or shortness of breath.
Hemorrhaging
Losing a large volume of blood. Saturation of a rag or towel in a few minutes of time.
Poisonings
Poisonings can be from inhalation, absorption, or ingestion. Patients who are in respiratory arrest, unconscious, or are mentally disoriented are usually referred to the EMS. Other poisoning victims with less serious symptoms should be referred to the local poison control center. Post the poison control number for your area on or near all telephones.
Seizures or convulsions
A condition where the patient may appear to be unconscious or in a trance for a short period of time. May be in conjunction with tremors and vomiting.
Stroke
Any of the symptoms listed below: Sudden numbness or weakness of the face, arm, or leg especially on one side of the body Sudden confusion, trouble speaking, or understanding Sudden trouble walking, dizziness, loss of balance, or coordination Sudden trouble seeing in one or both eyes Sudden, severe headache with no known cause
Sudden excruciating head pain, back pain, or abdominal pain
Any sudden intense pain in these areas may point to a life-threatening emergency.
medical assistant should document the patient’s refusal to follow instructions and state that he discussed the possible ramifications of not following the instructions. The medical assistant should always determine
what the patient’s course of action will be and ask the patient or patient’s representative to contact the office with a follow-up report once the emergency has been resolved.
DOCUMENTATION EXAMPLE:
04-12-XX 1230
Mrs. White, (wife of pt.) states that pt. c/o chest discomfort x 30 min. Pt. states, “It feels like a truck is sitting on my chest.” –heart hx, no radiation to jaw, neck, or arms. + N/–V. Instructed Mrs. White to contact the EMS, per telephone screening manual, page 36. The wife relayed the instructions to the husband. Husband refused the services of the EMS. Asked wife if I might speak to the pt. She asked the pt. but he refused. Wife stated that she would drive pt. to the ER. Explained the possible consequences of driving the pt. to the hospital. Wife stated that she understood the magnitude of the situation and that she would continue to encourage her husband to allow her to call the EMS. Wife will call once the emergency has been resolved. Callie Cane, CMA (AAMA)
CONDUCTING TELEPHONE SCREENINGS
Responding to Patients with Acute Symptoms The majority of patient screenings will be for patients complaining of acute conditions. Examples of patients with acute conditions include patients with possible urinary tract symptoms, flu symptoms, or migraines. Patients with acute symptoms are usually scheduled for a same-day appointment whenever possible or within 24 hours, but the medical assistant should always follow the protocol of the office in which he is working.
Providing Home Care Instructions Medical assistants may not give out home care instructions unless they have been preapproved by the provider and the standard requirements for telephone screening have been followed. This means following all protocol listed in the book and then transferring the responsibility to the provider by asking for the provider advice on whether or not home care instructions can be followed. The provider will approve the home care instructions listed in the manual, give his own set of instructions, or deny home care instructions and ask that the patient be offered an appointment.
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TABLE 7-4 Telephone Screening Dos 1. Do go through a telephone screening program to learn how to properly screen patient phone calls. Educational training starts in your medical assisting classes. 2. Do learn the policies and procedures for the office in which you will be working. 3. Do request some method of evaluation upon conclusion of training to ascertain that you are competent in screening patients and following office protocol. 4. Do represent yourself as a medical assistant. 5. Do always remain calm. 6. Do use an approved screening or protocol manual whenever you screen calls. 7. Do obtain reinforcement from a supervisor or provider when a patient complains of symptoms that are not listed in the manual. 8. Do thoroughly document all telephone screening encounters.
Documentation of Patient Screenings The documentation of telephone encounters is just as important as the telephone screening itself. Failure to document or poor documentation has been blamed for the defeat of some professional liability cases. Medical assistants who perform telephone screenings should learn what components need to be included in a telephone screening entry. Refer back to Table 4-6 for a complete listing of items to be included in the documentation of a telephone screening. Refer to Procedure 7-1 for a complete procedure for screening patients over the telephone.
Summary of Dos for Telephone Screenings Screening telephone calls can be stressful at times, but can also be quite rewarding. When you are instrumental in saving a life or assisting the patient in obtaining an appointment, it can be satisfying. Table 7-4 is a summary of things to do when performing telephone screenings.
SCREENING PATIENT TEST RESULTS One of the most important responsibilities of medical assistants is the screening of patient lab results. Lab
results reach the office via the telephone, lab printer, fax machine, computer, mail, or lab courier. Medical assistants who are responsible for monitoring test results must be extremely organized. When using paper records, lab reports should always be attached to the patient’s chart and given to the provider for review. Medical assistants must never give out any test results until they have been reviewed and released by the provider. They must also understand the importance of critical lab values.
Handling Critical Lab Results A critical lab value or panic lab value is best described as a value that requires the immediate attention of a qualified provider. It may or may not be considered life-threatening but usually is quite serious. These lab values should never sit on the medical assistant’s desk or in an electronic mailbox. The medical assistant needs to ensure that the results are given to the provider as soon as possible. Each practice should have a policy for handling critical lab values. Table 7-5 represents an example of a protocol policy. If the medical assistant is responsible for retrieving lab reports, he has ownership of those lab reports until
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E M R A P P L I C AT I O N Some labs provide a link that will interface with a dedicated modem by automatically downloading lab results to the practice’s hard drive in specially designated folders. The folders are reviewed throughout the day by the designated providers and results are distributed to the patient’s electronic files. Many lab programs, however, require selected personnel to check labs throughout the day on the lab’s Web site. This is accomplished
by entering a specialized authorization code that allows the worker to download the information from the lab’s Web site. Once the information is downloaded, it can be uploaded within the EMR and the results can be imported to the electronic task box of the designated provider. Any labs that have critical values should be flagged so that the provider is aware that the lab result needs immediate attention.
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TABLE 7-5 Sample Policy for Critical Lab Values LABORATORY RESPONSIBILITIES
MEDICAL ASSISTANT’S RESPONSIBILITIES
PROVIDER’S RESPONSIBILITIES
The lab will contact the office to say that they are sending over a critical lab value.
Write the name of the patient and the test into a special critical lab log.
Immediately read and evaluate result.
The lab will either fax or send results via the computer.
Retrieve the lab report off the fax machine or computer.
Implement a plan of action.
When using paper charts, pull the patient’s chart and attach the lab value to the front of the chart. When using EMR, send electronic messages to the provider’s mail box marked with a priority symbol to pull up the patient’s lab result. Verbally communicate the message to the provider to make certain that he checks his mailbox.
Either handle the lab personally or give the medical assistant the responsibility of notifying the patient and giving the patient instructions on how to proceed.
Respond to any directions given by the provider for contacting the patient and providing the patient with a list of instructions.
Document findings and course of action in the patient’s chart.
If the patient is not available, discuss with the provider what to do. Do not allow critical labs to lie on your desk until the office reopens. Document how the procedure was handled in the patient’s chart. Check the critical lab log to ascertain that all critical labs have been handled prior to leaving for the night.
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they have been reviewed by the provider and initialed for filing. It is easy for lab reports to accidentally get filed back into the patient’s chart or into another’s patient’s chart when the medical assistant becomes distracted. The lab report may even get buried underneath other files on the medical assistant’s desk. A failure to handle lab reports in an efficient manner puts the patient at risk for developing complications. The medical assistant must be organized and work diligently to make certain that all lab work has been properly reviewed, processed, and correctly filed.
Calling Patients with Test Results Once the provider reviews the patient’s test results he may send the results back to the medical assistant with an assigned task. The task may be any of the following: ❖ To call and inform the patient that the test results are normal. ❖ To call the patient and schedule an appointment to review the test results. ❖ To call and give the patient a list of instructions, which may include setting up the patient for another test, referring the patient to a specialist, having the patient change the way they are currently taking their medication, or starting the patient on a new medication, which may also involve calling in a prescription. Refer to Figure 7-7 for a sample of a progress note with a list of instructions for the medical assistant to give to the patient due to a critical lab value. Medical assistants work on these types of calls throughout the day. If the medical assistant is unable to reach the patient and the lab value was not a critical
Date/Time
12-12-XX 3:00 p.m.
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C R I T I C A L T H I N K I NG CHALLENGE A physician hands you a critical lab value result for a female patient with a low potassium level (an electrolyte important in heart function). He asks you to contact the patient right away and gives you a list of instructions to give to the patient. It is Friday evening and the office does not open again until Monday morning. The physician is late for a special dinner and leaves you all alone. You call the patient’s home phone number only to find out that the number has been disconnected. The patient does not list a cell phone number. You try to reach the patient’s daughter, who is listed as a contact, but there is no answer and no voicemail. It’s getting late and you want to go home. 1. What would be your most logical solution? 2. What are the possible consequences of waiting until the following Monday to contact the patient?
or abnormal lab value, the medical assistant may try again the next day. If still unable to reach the patient, the medical assistant may send the patient a standard letter that states all lab results were normal and to feel free to call the office with any specific questions. If the lab information or instructions are considered critical and the medical assistant is unable to reach the
Progress Note Chart # 89098 Patient’s Name: Little, Steven DOB: 02/17/55
12-12-XX 2:30 p.m.
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Will have MA call and inform pt. that PT level is elevated and that he should reduce his Coumadin from one 5 mg tablet each day to ½ of a 5mg tablet or 2.5 mg/day for five days. Pt. needs to f/u for another PT level on 12-18-XX. Ed Smith, M.D.
Called pt. and shared results of PT level and instructions above per Dr. Smith. Patient appeared to comprehend the information and repeated the info back after writing out the instructions. Scheduled pt. for an appointment on 12-18-XX for another PT level per Dr. Smith. Patricia Hathaway, CMA (AAMA)
FIGURE 7-7 A typical set of instructions given to patients when their PT level is abnormal
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E M R A P P L I C AT I O N Some of the more technologically advanced practices now provide patients with an online portal where patients can check their lab results. This is quite common in concierge medicine where patients pay an annual fee for continuous access to their provider and medical records. Patients can schedule their appointments, request drug refills, leave messages for the provider, and
patient, the medical assistant should notify the provider or supervisor to determine how to properly proceed. Refer to Procedure 7-2 for how to properly screen and follow up on patient test results.
CALLING IN PRESCRIPTIONS Another telecommunications function of the clinical medical assistant is relaying prescription information to the patient’s pharmacy. The medical assistant will need to check state and federal laws as well as the protocol of the office and the schedule of the drug to determine if this practice is acceptable for medical assistants. Prior to calling in the order, the medical assistant should ensure that he fully understands the order. If there are any questions, he should verify the medication order with the physician. Once verified, he may call or fax the order to the pharmacy. The following information should be given to the pharmacist: ❖ The medical assistant’s name and credential ❖ The physician’s name
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H I PA A PAT R O L The medical assistant may leave limited information with a receiver that is not listed on a privacy statement when leaving information on a patient’s answering machine. Information that may be disclosed under these conditions include the name of the office, the name of the medical assistant, and the telephone number for the patient to call.
check lab results online. All normal lab results are filed within the patient’s electronic record so that the patient can review the results, saving the practice time in calling the patients with the results. When results are abnormal, the patient may be sent an e-mail with instructions to either call the office or to schedule an appointment.
❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖
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The patient’s name and address The patient’s date of birth The name of the drug The strength or dosage of the drug The amount to be dispensed The directions on how to take the medication The number of refills The physician’s DEA number if the prescription is a controlled drug
If the pharmacist does not repeat the information back to the medical assistant, the medical assistant should ask the pharmacist to do so. The information should be documented in the patient’s chart. To learn more about creating and calling in prescriptions, refer to Chapter 32. To learn how to document a prescription within the patient’s chart, refer to Table 4-4 in Chapter 4.
SENDING FAXES The fax machine (Figure 7-8) is another type of telecommunications device and is frequently used to send patient data through the telephone lines. The fax machine makes copies of items such as lab, diagnostic and surgical reports, referrals, and correspondences and transmits them to the receiver. Copies can be sent from fax to fax or modem to fax. The medical assistant must apply FIGURE 7-8 A typical privacy rules whenever send- fax machine. (Courtesy ing PHI and do everything Panasonic Document Imaging Co.) possible to make certain that
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the intended recipient receives the information. All fax cover sheets should contain a confidentiality notice that states that the information is for the intended recipient only (Figure 7-9). It is good practice to notify the intended recipient via e-mail or telephone before sending information. Chapter 4 lists guidelines that should be used when completing a fax cover sheet and tips for sending faxes.
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ELECTRONIC MAIL (E-MAIL) Electronic mail (e-mail) is becoming increasingly popular in today’s medical office and is yet another form of telecommunications. The medical assistant may use electronic mail to communicate with: ❖ Supervisors, providers, and other coworkers ❖ Patients
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❖ Diagnostic centers, hospitals, and other types of medical facilities ❖ The billing office Confidentiality issues must also be addressed when sending e-mails. The proper techniques and etiquette for sending e-mails can be found in Chapter 4.
WORKING WITH TDD OR TTY DEVICES The Americans with Disabilities Act (ADA) requires businesses that provide services to the general public to comply with ADA guidelines. One of the guidelines is to provide deaf patients with auxiliary services or aids to ensure “effective communication.” To provide effective communication while in the office, the provider may use the services of an interpreter or a teleconferencing or videoconferencing device. To provide effective communication over the phone lines, the medical office may use a device known as a teletypewriter (TTY) or telecommunications device for the deaf (TDD) (Figure 7-10). This device allows users to type
messages to one another and may be used to schedule appointments, call patients with lab results, or to change the patient’s medication. There is now computer software that can be purchased through specific manufacturers and allows users to communicate with other TTY’s devices or TTY software used by the patient. It provides computer alerts to let the office know that the patient is trying to reach them. Refer to Chapter 8 to learn more about how to work with patients that are deaf.
Scheduling Appointments for Patients with Limited English The federal government mandates that any institution that receives government funding, including providers who receive Medicare and Medicaid payments, must make reasonable accommodations for patients with limited English. This usually means that an interpreter should be hired for the appointment. When an interpreter is not available in person, the office may consider using an interpreter over the phone or through video conferencing. Refer to Chapter 8 for additional information regarding patients with limited English skills.
VIDEO CONFERENCING
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Another form of telecommunications technology is teleconferencing or videoconferencing, which usually includes a group of providers or other health care specialists who come together to discuss health-related topics via the phone or computer. Videoconferencing is used to teach students how to perform various surgeries or other procedures and how to use the latest technological equipment. Videoconferencing may also be used to monitor patients that are chronically ill and unable to visit the provider due to the patient’s location or disability. The provider is able to assess the patient using video technology linked to a computer. Some advanced systems may also attach monitoring devices such as blood glucose units, ECG monitors, and blood pressure units from a home terminal. The provider can evaluate the tests while conferencing with the patient. Videoconferencing is slowly becoming more popular as a means for providing interpreting services for both deaf patients and patients with limited English.
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PROCEDURE 7-1 Perform a Telephone Screening Objective: The student will properly screen a patient over the telephone, while staying within the boundaries of medical assisting. HIPAA rules will be applied and the patient will receive proper instructions for how to proceed once the screening process is concluded.
Equipment/Supplies: ❖ Screening manual ❖ Patient’s chart
❖ Black pen
PROCEDURAL STEPS
RATIONALE
1. Properly identify yourself and state your title.
It is important for the caller to know your name in case he wants to reference you later regarding the call. It is also important for the patient to know your credentials so that he knows you are properly qualified to screen the call.
2. Properly identify the caller, using two identifiers.
You want to make certain that you know who you are talking to so that you can pull the correct chart.
3. Ask the caller if this is an emergency. If the caller states that it is not an emergency, you may place the caller on hold while you retrieve the chart. If using EMR, you do not have to put the patient on hold; simply bring up the patient’s electronic chart. If the caller states that the call is an emergency, proceed to number 5.
Time is precious during an emergency—you do not want to waste time pulling the chart when the patient’s life is at stake.
4. If the caller is someone other than the patient, only share information that is absolutely necessary to handle the call.
Patients may have a hard time verbalizing their symptoms if they are in distress, so they may ask a family member to make the call on their behalf. Be careful not to share anything other than what is absolutely necessary to effectively handle the call.
5. Ask the patient or caller for a description of the patient’s complaint.
This is necessary to know which part of the screening manual to reference.
6. Open the telephone screening manual and turn to the page that best describes the patient’s complaint (Figure 7-11). If there is no complaint listed in the screening or protocol manual that matches the patient’s symptoms, refer the call to the supervisor or one of the providers in the practice.
The medical assistant must never try to manage a call that is not listed in the protocol or screening manual. This may be considered “practicing medicine without a license.”
FIGURE 7-11 A medical assistant refers to the triage/screening manual while talking to the patient about symptoms.
continues
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continued
PROCEDURAL STEPS
RATIONALE
7. Ask the patient or caller the questions that are listed in the screening manual.
This is for screening purposes.
8. Once the patient or caller responds with a Yes response, give the instructions listed under the action column.
There usually is no need to proceed any further once the patient answers Yes to a particular symptom. Screening manuals are set up so that symptoms run from most severe to mild. (Check the policy of your office. Some providers want the medical assistant to ask all questions listed.)
9. If the patient refuses to follow the instructions listed in the manual, state the importance of following the instructions and state the consequences that may occur as a result of not following the instructions. (Consider forwarding the call to the provider.)
This is for legal purposes. Sometimes, patients will listen to the provider before they will listen to the medical assistant.
10. Query the patient to determine his course of action.
This is so the office knows what the patient’s intentions are.
11. Thank the patient for calling and conclude the call. Allow the caller to hang up first.
The patient may have something else to say and if you are first to hang up, you may not hear the patient request additional information.
12. Thoroughly document the call.
This is for reference and legal purposes.
DOCUMENTATION EXAMPLE:
10-22-XX 2:45 p.m.
TC: Pt. states that she cut the bottom of her L. foot on a piece of broken glass approx. x 1 hour ago. “Bleed ing has subsided quite a bit but starts up again when I bend my foot or start walking on it.” Last tetanus 15 years ago. –Rx, –OTC, Instructed pt. to come in for a 4:00 appt today, per page 112 of telephone screening manual. Sharla Day, CMA (AAMA)
PROCEDURE 7-2 Screen and Follow Up on Test Results (Determine the Order of Prioritization) Objective: To properly screen test results, to stack charts according to priority, and to contact the patient with results and instructions ordered by the provider.
Equipment/Supplies: ❖ Lab results ❖ Patient’s chart
❖ Black pen
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PROCEDURAL STEPS
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RATIONALE
1. Retrieve the completed lab reports from the lab printer.
This will vary from office to office. If using EMR, download the appropriate information.
2. Divide the labs according to their ranking in priority. Critical lab reports should be placed on top (write down the names of anyone with critical labs in a special critical lab journal).
It is important to put critical labs on top so they do not get overlooked. Placing the names of the persons with critical labs in a journal will spark your memory to make certain that those labs have been taken care of before going home for the day.
3. If you are not using electronic charting, pull the charts of the patients who have lab results. (These will usually be in the pending lab files.)
Never hand the provider a lab report without a chart for reference purposes.
4. Attach the labs to the charts. Keeping them in priority order, place the charts on the provider’s desk.
Charts that have critical lab values should be placed on top of the pile so that the provider can see them.
5. Once the provider signs off on the labs and lists instructions to give to the patient, review the instructions to make certain that you have a thorough understanding of what you are to tell the patient.
Do not give the patient incorrect information. Make certain that you understand the instructions before giving them to the patient.
6. Gather your chart, lab result, and black pen.
It is important to have these items for reference purposes.
7. Pull the patient’s privacy notice to determine how test results are to be handled.
Privacy notices usually have the names of persons who can receive PHI in case the patient is unavailable. It also lists whether or not you can leave information on an answering machine.
8. Place a call to the patient, properly identify yourself, giving the name of the office you are calling from and your title.
This allows the person receiving the call to know who the caller is and gives an indication of the importance of the call.
9. Identify the person who answered the phone. If the person answering the phone is someone other than the patient, ask if the patient is available. (If the patient is unavailable, check the patient’s privacy statement to see if you can leave test results and instructions with the person receiving the call (Figure 7-12).
You must know who you are speaking to, so you will know what information you can give the receiver and so that you can reference the receiver in your documentation.
FIGURE 7-12 This medical assistant refers to the privacy statement before leaving information with someone other than the patient. continues
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PROCEDURAL STEPS
RATIONALE
10. When speaking with the patient or someone listed on the privacy statement as being able to receive the results, give the test results and any instructions given by the provider.
The sooner the patient or patient’s representative receives the information, the sooner the patient can make any necessary adjustments.
11. If the person receiving the call is not listed on the privacy notice, leave only your name, the office name, telephone number, and a message to have the patient call you back.
You must abide by HIPAA rules.
12. Ask the patient or patient’s representative to repeat the information.
This ensures that the receiver understood the information.
13. Thank the patient or patient’s representative for his time and encourage him to call back with any pertinent questions.
This illustrates professionalism and lets the patient or receiver know if questions do come up, they don’t have to feel embarrassed about calling.
14. Allow the patient or receiver to hang up first.
The receiver may think of one more question. You may miss it if you hang up first.
15. Document the telephone call.
This is for quality of care and legal issues.
DOCUMENTATION EXAMPLE:
11-30-XX 1500
Called and gave pt. both lipid & liver panel results. Instructed pt. to reduce her Lipitor from 20 mg daily to 10 mg daily by cutting her 20 mg tabs in half and only taking a half a tab/day. Also instructed pt. to continue the low cholesterol diet and the exercise program and to F/U in 90 days for more blood work per Dr. Wang. Asked pt. if she needed a new Rx before next visit. She stated that she had plenty of pills left, especially since she was now going to be cutting them in half. Pt. repeated instructions back and appeared to have a clear understanding. Pt. did not want to schedule a F/U appt. today but stated that she would call back sometime next month to schedule next appointment. Lori Foster, RMA
Chapter Summary Screening patients over the telephone, calling in prescriptions, and calling patients back with lab results are all important responsibilities. Medical assistants must be properly trained to perform these procedures correctly and understand the legal issues involved with performing these tasks. Telecommunications devices are the lifeline of the office. The employees who are assigned the task of using these devices must have wonderful communication skills and understand the importance of customer service.
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FIELD APPLICATION CHALLENGE The husband of one of your patients calls to tell you that he just noticed that his wife’s mouth is drooping on the left side and that she is unable to use her left arm. He goes on to say that his wife appears to be a bit confused and has a terrible headache. He wants to know if he should drive her to the office for an evaluation. 1. What do you suspect may going on with the patient?
2. As a medical assistant, you do not have the authority to diagnose patients. But do you feel it is important that you recognize symptoms of common emergency conditions, so that you can instruct patients in the proper manner? 3. What would most office protocols typically suggest for someone experiencing this patient’s symptoms?
Chapter Assessment 1. An example of a telecommunications device is: a. a telephone. b. a fax machine. c. a computer modem. d. all of the above. 2. Why is it considered wiser for the medical assistant to take on the role of a screener when talking to patients about their concerns than to take on the role of a triager? a. Taking on the role of a screener forces you to follow a protocol that was designed or approved by the provider and to obtain clarification in cases that do not match the protocol book. b. Screening patient calls gives you more freedom to use your own assessment skills and has a higher degree of responsibility than triaging. c. Taking on the role of a triager requires more decision making and could put you at the risk of practicing medicine without a license. d. Both a and c 3. This type of screening tool lists specific symptoms under a list of appointment actions: a. screening grid. b. algorithm. c. appointment grid. d. none of the above.
4. Before screening patient concerns over the telephone, the medical assistant should: a. ask for a raise because of the liability ensued with screening patient calls. b. go through a training program to learn how to properly screen patient calls. c. use an approved protocol manual whenever screening patient calls. d. both b and c. 5. What are desired traits of a good telephone screener? a. A person who loves to talk on the phone b. A person who hates working the floor c. A person who has wonderful communication and documentation skills d. A person who has a license to practice medicine 6. In regards to HIPAA, medical assistants can share patient information when: a. Medical information directly pertains to the person’s involvement with the patient or patient’s care. b. You speak to the spouse of a patient. c. The patient has listed the caller as someone that you can share information with on the privacy disclosure statement. d. Both a and c.
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7. When talking to a patient who is experiencing a life-threatening condition, you should always: a. have the patient call the EMS. b. notify the provider. c. follow the office protocol for handling a life-threatening event. d. follow your gut feeling.
Web Activities 1. Using the Internet, look up the local number of the poison control center in the city in which you live. 2. Type the following words into a search engine: “Online Patient Portal.” Investigate different companies that offer online portals as part of their EMR software. List two examples of different companies that provide these services and list all the different functionalities available to patients that use these services.
CONNECTION Using your StudyWARE CD-ROM: ❖ Complete the Hangman and Concentration activities for this chapter. ❖ Complete the Quiz for this chapter in Test Mode.
THE DVD LINK On your StudyWARE CD-ROM, go to the DVD Challenge for this chapter. View the DVD clip and respond to the following questions: 1. In the first scenario, what was the reason that Jae Min didn’t pull the patient’s chart herself when talking to Mrs. Hernandez on the phone? 2. We saw Jae Min ask Mrs. Hernandez several questions so that she could determine if Mrs. Hernandez was in the middle of a life-threatening emergency. Do you think that there was a need to ask the patient so many different questions when it was clear that the patient was in the middle of an emergency early in the call? 3. In the second scenario, the medical assistant scheduled the patient for a 3:00 p.m. appointment. Why was scheduling the patient for an appointment an inappropriate response?
C H A P T E R
Assisting Patients with Special Needs Chapter Outline Legal Issues and Special Needs Patients Laws for the Hearing Impaired or Deaf Patient Laws Assisting the Sight Impaired or Blind Patient Accessible Design Standards for Persons with Physical Disabilities Laws for the Patients with Limited English Proficiency (LEP)
Working with Patients with Special Needs Cultural Diversity in Health Care Working with Sight Impaired and Blind Patients Working with Hearing Impaired and Deaf Patients Working with Older Adults Working with the Pediatric Patient Working with Physically Disabled Patients Working with Patients Who Are Mentally Impaired
8 Essential Terms ADA Standards for Accessible Design American Sign Language (ASL) Americans with Disabilities Act (ADA) auxiliary services Civil Rights Act conceptually accurate signed English (CASE) cultural diversity dementia guide dogs limited English proficiency (LEP) mental health mental illness mental impairment mentally challenged physical disability postlingual prelingual continues
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KEY COMPETENCIES
CAAHEP
ABHES
Effectively Communicate with Patients from Different Cultures
III.C.3.c.3.b
VI.A.1.a.2.m
Effectively Communicate with Patients Who Are Sight Impaired or Blind
III.C.3.c.3.b
VI.A.1.a.2.m
Effectively Communicate with Deaf Patients When an Interpreter Is Present
III.C.3.c.3.b
VI.A.1.a.2.m
Effectively Communicate with a Hearing Impaired or Deaf Patient That Speech Reads
III.C.3.c.3.b
VI.A.1.a.2.m
sighted guide assistance signed English signed exact English (SEE) telecommunications device for the deaf (TDD) Telecommunications Relay Services (TRS) teletypewriter (TTY)
Developmental Objectives After completing this chapter, you should be able to: 1. Correctly spell and define the essential terms. 2. Explain the purpose of the Americans with Disabilities Act (ADA) and list what groups are included under this provision. 3. List ways that the office can become compliant with ADA guidelines to assist sight impaired and blind patients. 4. Give four examples of auxiliary services and aids that can be used to assist the hearing impaired and deaf patients. 5. List six examples of “accessible design” features that can accommodate patients who have disabilities. 6. Describe obligations of the office in providing an interpreter for patients with limited English. 7. Explain the term cultural diversity and list some commonalities among similar cultures. 8. Describe why the implementation of many gestures is discouraged. 9. Explain the procedure for providing sighted guide assistance and briefly describe the procedures for accessing elevators, stairways, and doorways. 10. List tips for working with older adults and pediatric patients. 11. List tips for working with mentally impaired and mentally challenged patients.
Introduction A health care worker must have excellent communication skills. The majority of responsibilities for the clinical medical assistant involve direct patient care. Because a clinical medical assistant spends a great deal of time with patients, effective communication with all types of patients is vital. Before a medical assistant can be a good technician, she must be a good communicator. If the assistant lacks the ability to properly communicate, it can impede the ability to perform well technically.
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Illness or injury can strike anyone at any time, regardless of age, religion, ethnic background, or disability. The medical assistant must learn how to work with all types of individuals in spite of language or cultural differences and must learn how to properly accommodate individuals with disabilities. Learning how to effectively communicate with these types of individuals is a lifelong process that begins during medical assistant training. The contents of this chapter will set the foundation for working with patients with special needs. You will build on the foundation throughout your professional career by attending continuing education courses related to working with patients with special needs, and through your own trial-anderror efforts. Just as your technical skills improve with time and practice, so will your communication skills.
and religion through the Civil Rights Act of 1964. It prohibits discrimination on the basis of disability in: private sector employment, services rendered by state and local governments, places of public accommodation, transportation and telecommunication services.” This act lays the foundation regarding procedures that should be followed for patients with disabilities including:
LEGAL ISSUES AND THE SPECIAL NEEDS PATIENTS
Businesses, including medical offices, are required by law to accommodate hearing disabled or deaf persons by furnishing appropriate auxiliary services and aids whenever necessary to ensure “effective communication” (Title III of the Americans with Disabilities Act, section 36.303). Table 8-1 lists some examples of auxiliary aids and services provided under the ADA. Because each patient’s ability to communicate is different, the office will need to determine what services, materials, or devices are necessary to effectively communicate with each individual hearing impaired or deaf patient. In many instances, this is determined at the time the appointment is scheduled by either the patient or caregiver of the patient.
In addition to being able to effectively communicate with special needs patients, the medical assistant must have a good grasp of laws that assist some of the special needs patients that frequent the medical office. Failure to adhere to these laws can set the office up for possible litigation. According to the U.S. Department of Labor, “The purpose of the ADA or Americans with Disabilities Act is to extend to people with disabilities, including disabled veterans, civil rights similar to those now available on the basis of race, color, sex, national origin,
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Persons with hearing impairments or who are deaf Persons with speaking impairments Persons with physical disabilities Persons with visual impairments or who are blind Persons with mental impairments or disabilities
Laws for the Hearing Impaired or Deaf Patient
TABLE 8-1 Auxiliary Aids and Services That Aid in Communication AIDS THAT REQUIRE THE SERVICES OF OTHER PEOPLE
AIDS THAT REQUIRE SPECIAL EQUIPMENT
AIDS THAT REQUIRE A COMPUTER OR TELEVISION
Qualified Interpreters Deaf interpreters who are specially trained to interpret what is being stated during a medical office or hospital visit
Assisted Listening Devices Devices that help to amplify sound, such as hearing aids, head sets, etc.
Computer-Aided Transcription Services Turns verbal audiotaped information into a written transcript
Note Taker A specially trained individual who takes written notes for deaf patients during meetings, office visits, school and college courses
Telecommunication Devices for Deaf Persons (TDDs) A device that allows a deaf person to type information over the phone lines to another person with a TDD
Closed and Open Caption Captions that display dialog being stated on a TV screen. May be used during a video presentation or video conference.
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To effectively communicate when scheduling appointments, some medical offices have a device referred to as a teletypewriter (TTY) or telecommunications device for the deaf (TDD). These devices allow users to type messages between each other. When the office does not have a TTY/TDD, the deaf caller may use Telecommunications Relay Services (TRS). As shown in Figure 8-1, the relay operator will dial the requested number and relay the conversation between the two callers. When talking to a relay operator, the medical assistant should talk as though talking directly to the patient. The operator is required to type anything said back to the deaf caller. Some telephone companies now offer a video relay for their customers. The deaf caller signs the message to the relay operator, who is a sign language interpreter. The interpreter speaks the message to the hearing person and then signs back the message from the hearing person to the deaf person. Personal digital assistants (PDAs) or cell phones with a text writing feature now provide deaf persons with the ability to text messages directly without going through relay. Video conferencing and other Internet technology services can also provide the office with remote access
FIGURE 8-1 An example of a telecommunication relay service: (a) The deaf patient communicates with the relay operator by typing into her TDD. (b) The relay operator places the call to the medical office for the patient. (c) The medical assistant is able to communicate with the patient with the assistance of the relay operator. (a)
TOOL BOX
C R I T I C A L T H I N K I NG CHALLENGE A deaf patient schedules an appointment using a relay operator. You ask the operator to ask the patient if she will need the office to schedule an interpreter for the visit. The operator states that the patient doesn’t feel an interpreter will be necessary because her friend is going to come with her and she just finished a sign language class at the community college. 1. List at least three reasons why using the friend in this scenario is not a good decision. 2. What would be an appropriate response for you to give to the patient?
to sign language interpreters and oral interpreters (individuals who mouth what is being stated and use special gestures for clients who cannot read sign language) at a reasonable price. Offices that serve a large number of deaf patients may find it more cost efficient to have one examination room with video conferencing equipment rather than hiring an interpreter for each office visit. As technology changes, the office will need to update its equipment as well. It is important to research the latest technology available to serve special needs patients most effectively and efficiently.
Laws Assisting the Sight Impaired or Blind Patient (c)
(b)
The ADA requires that admission of service animals be permitted for patients who have disabilities that would require them. A guide dog should always be under the control of the patient. New building codes require office entrance ways, exit signs, bathrooms, and elevator controls to have Braille plates for identification purposes (Figure 8-2). For more information about laws that assist the blind, explore the American Foundation for the Blind’s (AFB) Web site at www.afb.org.
Accessible Design Standards for Persons with Physical Disabilities Since 1992, the ADA has required all new public and commercial facilities to comply with the
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before, during, and following the appointment. It can also lead to legal difficulties for the office. Because of this the clinical medical assistant should routinely scan hallways and patient rooms to make certain that there are no barriers that would impede physically handicapped patients from getting through or potentially cause patients to injure themselves.
Laws for Patients with Limited English Proficiency (LEP) Another act that must be considered when referring to special needs patients is Title VI of the Civil Rights Act. This act requires entities receiving federal assistance from the Department of Health and Human Services (HHS)—including providers who participate in Medicare or Medicaid programs—to provide interpreters for patients with limited English proficiency (LEP). An individual is considered LEP when English is not the primary language or the patient is not literate. Providers must demonstrate that they have taken the appropriate steps to provide those patients with limited English-speaking or -reading abilities the services that are necessary to ensure effective communication.
Methods Used to Assist Patients with LEP FIGURE 8-2 A Braille plate allows a blind patient to identify where the bathroom is located.
ADA Standards for Accessible Design. These standards mandate construction companies to design buildings that are accessible to all persons, including those who have dexterity and limited mobility problems. Other groups addressed in this standard include individuals with visual and hearing impairments. Examples of ADA standards for handicap and wheelchair accessibility features include: ❖ Adequate number of handicapped parking spaces ❖ Wheelchair ramps to buildings with elevated entrances ❖ Wider elevators, doorways, and hallways ❖ Lower service counters ❖ Handicapped bathrooms designed to accommodate patients who are in wheelchairs While many of these guidelines do not directly affect the communication process, failure to comply with the guidelines can directly affect the patient’s mental state
The medical office has an obligation to provide oral language assistance to all patients with LEP. Methods that can be used for oral assistance include: ❖ Hiring staff members that are bilingual or multilingual ❖ Hiring staff interpreters ❖ Using interpreters from an interpreting service ❖ Teleconferencing with an interpreting service Brochures should be designed to accommodate the special ethnic populations that reside in the community. They should state that interpreting services are available to the patient at no additional charge.
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FI E L D S M A R T S Being bilingual or multilingual will give you added value to employers in offices that have great diversity within their patient population.
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S I T E C H EC K As a site reviewer, I’ll randomly pull charts from patients of different ethnic backgrounds to determine if an interpreter was used for patients needing assistance. The office should be able to provide paperwork attesting that interpreters used in the practice are from reputable agencies or are certified and are, in fact, qualified to perform medical interpreting.
vice line that can provide immediate translators 24 hours a day, seven days per week. Telephone interpreting is usually more economical and can be accessed quickly. The Department of Human and Health Services (HHS) also requires offices to comply with standards that require written translation of materials regularly used by patients such as consent forms, privacy statements, and a listing of services that are provided by the medical office. To learn more about assisting patients with LEP, go to www.usdoj.gov/crt/cor/.
WORKING WITH PATIENTS WITH SPECIAL NEEDS The remainder of this chapter focuses on the various types of special needs patients and the challenges a medical assistant may face when caring for these types of patients. The medical assistant must find ways to effectively communicate with these patients in order to provide the patient with the best possible care.
Cultural Diversity in Health Care The term cultural diversity incorporates several variables including ethnicity, race, and religious beliefs. Webster defines culture as the “customary beliefs, social forms, and material traits of a racial, religious, or social group.” Diversity is a term that identifies the unique differences in various cultures. The United States is one of the most culturally diverse countries in the world. Data from the 2000 U.S. Census states that almost one-third of the U.S. population is from racially, ethnically, or culturally diverse groups. By the year 2030, the U.S. Census predicts that this number will grow to 40%. As diversity numbers continually increase, it is more important now than ever for medical assistants to learn
H I PA A PAT R O L Anyone who has access to patient records should sign a confidentiality statement. This includes private contractors such as interpreters. A private interpreter contracting with your organization or office should be able to verify that she has had formal HIPAA training and sign a con-
fidentiality statement. When using the services of an interpreting company, the company usually assumes responsibility for providing their interpreters with HIPAA training and should be able to supply the office with confidentiality statements.
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In order for providers to be in compliance with agencies that are nationally accredited, such as the Joint Commission ( JC) and the National Committee for Quality Assurance (NCQA), the provider must establish that the interpreters used are qualified, meaning that they have been specially trained for the assignment. Qualified medical interpreters should be fluent in both the patient’s language and English and have gone through special training for medical assignments, demonstrating mastery of the skill through competency testing. The American Translator Association (ATA) provides a testing exam for Certified Translators, which helps to ensure that the translator is proficient. Most interpreting companies provide interpretation for multiple cultural groups. These companies usually provide training and testing for their interpreters and require the interpreters to be bonded. The company normally provides HIPAA training and require each interpreter to sign a confidentiality statement, simplifying the amount of work that the office has to perform. The office can schedule an in-office interpreter or may choose to use a special interpreter telephone ser-
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about different cultures and gain a better understanding of the customs and practices for the cultural groups that they serve.
Easing the Culturally Diverse Patient Good medical assistants work hard to make every patient feel at ease. The following information lists a step-by-step approach that can be taken by the medical assistant to help culturally diverse patients and their families feel more comfortable during the office visit. 1. Begin the visit by introducing yourself and stating your title. 2. If you are a different gender than the patient, ask the patient if she would prefer someone of her gender to conduct the interview (Figure 8-3). 3. Ask the patient for assistance with the correct pronunciation of her name. 4. Ask the patient to introduce any family members or friends that are present. 5. Be conversational by starting with a question about the patient’s family or career. This demonstrates a caring attitude toward the patient and family members. 6. Before starting the formal patient questioning, ask the patient and family members to state their goals for the visit. 7. If an interpreter is not present and the patient has limited English, give the patient written materials that explain her rights to have a qualified inter-
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preter present during the interview process. If the patient is going to use a family member to perform the interpreting, ensure that the family member understands the seriousness of the interpreting. Using non-adult children as interpreters is usually discouraged. Instruct the patient and patient’s family members to stop you at any time if they need something more clearly stated. Observe the patient for cues on how she feels regarding eye contact, gestures, and proxemics (the amount of distance that one needs in order to feel comfortable when sitting or standing next to another person). This will help you get a feel for what is and is not comfortable to the patient. Do not ask the patient to do anything that would make her feel uncomfortable unless absolutely necessary. Do not judge or criticize the patient about her cultural or religious beliefs. Be sensitive to the patient’s cultural beliefs with regard to disrobing. Use extra drapes and keep the patient covered completely except during times when it is absolutely necessary to remove articles of clothing. Explain all procedures before you perform them.
Refer to Procedure 8-1, Effectively Communicate with Patients from Different Cultures, for a complete procedure.
Working with Interpreters FIGURE 8-3 Always ask patients of the opposite gender if they would prefer a medical assistant of the same gender.
When the patient has limited English proficiency, the services of a professional interpreter should be used whenever possible, because: ❖ Professional interpreters have specialized training in medical interpreting to handle the types of communication that are common during medical encounters. ❖ Although family members may be bilingual, they may not possess the elaborate language skills that are necessary to properly translate medical information. ❖ The patient may withhold information if a family member is performing the interpreting to avoid revealing sensitive personal information to family members. ❖ The patient’s family member may be hesitant to translate certain findings from the provider to the patient because she may not want to worry the patient.
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If an interpreter is present, place the interpreter’s chair next to the patient’s chair and angle the chairs so that they just slightly face each other. Place your chair across from the patient’s chair centered between both the patient and interpreter (Figure 8-4). Talk clearly and avoid using slang or medical jargon. Speak in simple phrases and avoid long sentences. Always speak in the first person as though you are speaking directly to the patient. Avoid saying phrases like, “Ask the patient” or “Tell her….” The conversation should be directed toward the patient but you should make certain that the interpreter can understand what is being said as well. Timing is critical when working with a translator. The translator must listen to the ques-
Body Language and the Communication Process Body language is an integral part of the communication process. Even when working with persons from the same or similar cultures, gestures or body language can change the entire meaning of what is stated. Table 8-2
FIGURE 8-4 A room should be set up properly when working with an interpreter and a patient with limited English.
tion, process it, and translate the question from English into the language of the patient. The patient will then respond to the question and the translator once again will need to translate the patient’s response back into English. Make certain that the translator is finished before proceeding with the next question. You should be looking for nonverbal cues from the patient and make certain that they match what the interpreter is relaying. Always ask the patient to repeat back any instructions to ensure a complete understanding of the instructions. Figure 8-4 illustrates a room that has been properly set up when working with an interpreter.
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provides general information regarding the use of body language and gestures and states how these movements might be perceived to patients from other cultures.
Commonalities among Different Cultures and Avoiding Stereotypes It is important to note commonalities in various cultures in order to improve communication, which ultimately means better service and care for the patient. A better understanding of what is considered “offensive” or what is considered “acceptable” for the different popu-
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FI E L D S M A R T S If your patient backs away from you or moves toward you, do not be offended and do not reposition your chair. This could well be a sign that the patient is uncomfortable with the spacing of the chairs. Allow patients to position the chairs in a manner that is comfortable for them.
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TABLE 8-2 Interpretation of Body Language and Gestures by Different Cultures Eye Contact
Considered respectful in Western civilization and in Latin countries but Latin Americans may not return eye contact, as a way of demonstrating respect. Asians and Middle Easterners may consider direct eye contact to be offensive in particular situations.
Touching
Usually limited in the Asian population but practiced more in Latin and Russian populations. Persons of the opposite sex do not normally shake hands in Asian countries. Any touching between members of the opposite sex is considered offensive by Middle Easterners.
Gestures
Different gestures mean different things to people in different cultures. Shaking your head from one side to the other indicates a “No” response in Western civilization but in other countries such as Taiwan and Bulgaria this gesture means “Yes.” Some Asian cultures point their finger when calling animals, so may be highly offended if someone points to them. A warm smile is considered acceptable by most civilizations.
Proxemics (the use of space)
Westerners usually require more space when conversing with another individual than persons from other countries. Middle Easterners and Hispanics are usually comfortable with less space.
lations served will help to keep the communication door open. Offending the patient by making gestures or saying things that are not considered appropriate can jeopardize the relationship, which may cause both emotional and physical stress to the patient. Just as there are unique differences in various cultures, there are also individual differences and preferences within each person that may be influenced by gender, education, religion, subcultures, age, reason for migration, and socioeconomic status. It is important that medical assistants examine their personal views on cultural issues and replace negative thoughts with positive thinking. Neither past experiences with individuals from other cultures nor family prejudices can be allowed to influence the service that a patient receives. Table 8-3 is a tool that can be used to help understand usual customs and practices of people from various cultures. The chart provides only a small sample of cultures present in the United States. Persons living in areas with diverse populations should learn more about the usual customs and beliefs of those groups so that they can better serve those patients. Also, the table only provides generalities about specific cultures. In practice, each individual is unique and may not fit the models described in the table.
Working with Sight Impaired and Blind Patients Attitude is important when working with visually impaired patients. The medical assistant’s views regard-
ing the patient’s abilities, needs, and interests can have a great effect on the patient, family members of the patient, and coworkers. Never assume that patients will be unable to perform a specific function just because they are blind. Blind patients have learned how to maneuver in spite of their disability and hence, are capable individuals. A large percentage of blind people have degrees, hold jobs, and live independently. Some individuals make the mistake of speaking loudly or shouting at blind people. Blind patients may
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C R I T I C A L T H I N K I NG CHALLENGE During the chief complaint segment of an in-office screening, an Iranian female patient complains of lower abdominal pain. She also has some vaginal symptoms. You instruct the patient to remove her clothes from the waist down. The patient and her husband appear quite distressed by the instructions and refuse to comply. 1. How should you respond to the couple’s distress? 2. What types of reinforcement techniques can you use to help the patient and husband comply with the instructions?
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TABLE 8-3 Cultural Diversity Chart CULTURAL GROUP
COMMUNICATION FACTS
HEALTH CARE BELIEFS
Asian Patients
Usually nonverbal; may be more formal than Americans; usually respectful of persons in authority positions; avoid direct eye contact (direct eye contact implies equality); touching may be limited; silence may be used to emphasize an important point; nonverbal cues are important; family structure is hierarchical; usually respectful toward elders.
Believe in traditional medicine and remedies; treatment decisions are often made by family members; may not feel com fortable with modern diagnostic testing, surgeries, and treatments; usually respectful of those in the medical field; believe that blood is the source of life and that it isn’t regenerated; may be apprehensive about having blood drawn.
Hispanic Patients
May be bilingual and may revert back to native language when stressed; eye contact considered respectful, though prolonged staring considered disrespectful; touching and hugging considered customary; small talk is usually welcome prior to actual conversation; quite family oriented and enjoy talking about their families; family structure is close with nuclear and extended family members such as godparents; respect the wisdom of elders; emphasize interdependence over independence.
May believe that disease is caused by an imbalance of hot and cold principles; believe that health is maintained by avoiding exposure to extreme temperatures and by balancing the intake of certain foods and beverages; traditional medicine is the major belief and may include many folk remedies; may consult a healer for disease intervention; will normally go along with scientific medicine in severe cases of illness.
Middle Eastern Patients
Passionate about cultural beliefs and customs; eye contact with the opposite sex is avoided out of propriety issues; women are modest and usually only leave their hands and faces uncovered (this may present a problem with disrobing); touching between members of the opposite sex is avoided; touching and embracing of the same sex is common; will usually raise voice to emphasize something that is important but no anger is meant; may get close when speaking; usually comfortable with closer proxemics than those from Western populations; family structure involves the husband being responsible for the family and husband will frequently do the talking for members of his family; if husband is deceased, the eldest male typically makes the decisions.
Believe various causes of disease include “hot” and “cold” factors and the “evil eye”; expect immediate pain relief from health care professionals; usually have great respect for health care providers; male health care providers are prohibited from examining female patients; may refuse female providers for male patients; interested to know what ingredients are in medicinces due to religious restrictions.
Russian Patients
Put a great deal of emphasis on hand gestures and facial expressions; believe in direct eye contact; passionate about their beliefs; family structure involves decision making by the father, mother, eldest son, or eldest daughter; family oriented great respect for elders.
Do not want to hear bad news; bad news is usually given to someone other than the patient and then shared with the patient later (consider HIPAA procedures though); usually more trusting of home remedies than traditional Western medicine; expect detailed explanations of any procedures or treatments since they don’t always trust the physician’s thoughts on treatment; may not be compliant about taking medicine.
This chart was compiled from information the following resources: • Estes, M. E. Z. (2001). Health Assessment & Physical Examinations (3rd ed.). Delmar Cengage Learning, Clifton Park, NY. • University of Michigan Health System, Enhancing Your Cultural Communication Skills. In Cultural Competence for Clinicians. Retrieved May 15, 2007, from University of Michigan Health System Web site: www.med.umich.edu/pteducation/cultcomp.htm. • Hogue, V. W. (2005). Multicultural Issues that Influence Patient Care Outcomes, DiabeteSource, 8(1), 1–2.
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not be able to see, but they are not deaf. This may be insulting to the patient. Avoid “talking down” to blind patients; that is, do not make them feel as though they have a comprehension problem or a learning disability just because they are blind. Continually communicate with blind patients so that they know what is going on, but communicate at the patients’ level of understanding. Most blind or visually impaired patients have learned to be independent. Never assume they want your help. Always ask if they need sighted guide assistance before trying to assist them. The following list presents tips that are helpful to know when assisting blind patients: ❖ Use verbal cues. Always let the patient know when you have entered an area by introducing yourself and stating your title. Alert the patient when you are going to leave an area as well. ❖ Out of respect for the patient, you should look directly at the patient as you speak, and position yourself at the same level as the patient. Blind people have a very good sense of proxemics. ❖ Shake hands only if the patient extends the hand. ❖ Introduce new people as they enter the area and let the patient know where people are positioned in reference to the patient. Using positions of the clock may be helpful in this situation (for instance, “Mrs. Jones, Carrie is on your left side at about the 9:00 position.”). ❖ Alert the patient before you touch any part of the body so that the patient is not startled (for example, “Mr. Tedrow, I am getting ready to clean your right arm with alcohol.”). ❖ Continue using “sighted words” such as look, see, or read, as well as phrases such as “I’ll see you later.” Blind patients have the same language as the sighted. Avoiding these words will make both parties uncomfortable. ❖ Never move a visually impaired patient’s personal belongings without the patient’s knowledge and consent. ❖ Keep the area safe. Make certain that there is nothing in the path of the patient to trip over or run into.
Providing Sighted Guide Assistance There will be times when the patient may benefit from some extra help in maneuvering around the office. This is especially true if the patient is not a regular patient and is unfamiliar with the office surroundings. The patient may use a white cane or have a guide dog. With
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a guide dog, the patient will usually not need extra assistance. If a guide dog is not present, the patient may be more accepting of assistance. The following list gives some suggestions for providing sighted guide assistance: ❖ Ask patients if they would like to have sighted guide assistance. Do not be offended if they refuse. They may feel strongly about their independence or have experienced a negative encounter in the past with someone who did not know how to properly lead. ❖ Stand next to the patient and gently touch the patient’s elbow, forearm, or back of the hand with your hand. This will signal the patient to take your arm. ❖ Keep your arm relaxed and down by your side, allowing the patient to grasp your arm rather than you grasping the patient’s arm. The patient will usually embrace your arm just above the elbow. ❖ Walk about a half step in front of the patient toward the inside of the patient so that the patient can feel your body movements (Figure 8-5). ❖ Walk at a comfortable pace and avoid dragging the patient. ❖ When moving through a narrow area, warn the patient and move your arm diagonally across your back. The patient should straighten her arm and walk directly behind you. This will permit you and the patient to move single file through the narrow area. FIGURE 8-5 Notice how the medical assistant walks about a half step in front of the blind patient toward the inside of the patient so that the patient can feel the medical assistant’s body movements.
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Navigating Stairs: Pause and alert the patient when you are at the top or bottom of a stairway. Inform the patient of the number of steps and whether you are going up or down the stairs. Have the patient grasp the railing with his free hand as he holds on to your arm with the other hand. Pause when you get to the edge of the first step so the patient can touch the edge of the step with his foot. Both you and the patient should walk in rhythm with one another and you should always be one step ahead of the patient (Figure 8-6). Pause and alert the patient when you have reached the last step.
Navigating Doorways: Let the patient know that you are at a doorway and describe whether it is a push or pull door and on what side the door opens. Position the patient so that she is on the hinged side of the door. Open the door with your guiding arm so that the patient senses where the handle is located. Have the patient place her free hand against the door, sliding it over to replace your hand on the handle (Figure 8-7). Release your hand from the handle and guide the patient through the doorway.
FIGURE 8-6 An example of the proper way to lead a blind person when ascending stairs.
FIGURE 8-7 An example of the proper way to lead a blind person through a doorway.
❖ Warn the patient when there are obstacles ahead or when you are going to make a turn, pass through a doorway, or go up or down steps.
the harness is on to prevent the dog from becoming distracted. Once the harness has been removed, the dog is like any other dog and can eat, play, and sleep.
See Procedure 8-2, Effectively Communicate with Sight Impaired or Blind Patients, for more information.
Working with Guide Dogs
Working with Hearing Impaired and Deaf Patients
Many people have dogs and are intrigued when they see a guide dog. Guide dogs have been specially trained to guide visually impaired or blind patients. Whenever a guide dog has a harness on, it means that the dog is “working.” Both the blind person and the dog are a team. Do not try to feed, speak to, or pet the dog when
Many people struggle with hearing loss but may be ashamed to admit it. Hearing impairments can range from slight to moderate impairments and in some cases, the patient may be totally deaf. Patients with mild to moderate hearing loss may be referred to as hearing impaired or hard of hearing. The term hearing impaired,
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F IEL D S M A R T S Seating a Blind Patient: Before seating a blind patient, explain the details of the seating. Describe whether the seating is a couch or chair, the height of the seating, and whether the seating has arms. When approaching the seating from the front, walk the patient up to the front of the chair, allowing her knees to just slightly touch the front side of the seat. Place the patient’s hand on the handle of the chair and allow the patient to take over. When approaching the chair from the rear, walk the patient in a forward motion toward the back of the chair, placing the patient’s hand on the back of the seat (Figure 8-8). Release the patient’s hand and allow her to seat herself.
FIGURE 8-8 An example of the proper way to seat a blind patient.
however, may not be considered culturally acceptable to some deaf patients. Accommodation factors for each patient will be based on the type and degree of hearing loss as well as the individual preference of the patient. The following list provides some tips that can be useful when working with patients with slight to moderate hearing impairments: ❖ Encourage patients to use their assistive hearing devices during the visit. ❖ Place the patient in a quiet room. Select rooms that are well-insulated with fabrics and carpeting. This will assist in reducing background noise.
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❖ Sit directly across from and at the same level as the patient so that the patient can see your lip movement. ❖ Speak clearly and in a normal tone. Avoid shouting at the patient. ❖ Use gestures to enhance what is being stated. ❖ There may be times when you need to speak to the patient when she is not in full view of you. When this is necessary, gently tap the patient on the shoulder to let her know you are going to speak. ❖ Ask the patient to repeat back any instructions given so that you can ascertain that the patient understood the information. ❖ Always give the patient written instructions and include family members in the discussion when appropriate.
Working with Severely Hearing Impaired or Totally Deaf Patients The beginning of the chapter discussed the office’s responsibility in providing an interpreter for deaf patients as well as auxiliary services and aids available to deaf patients. The medical assistant may be responsible for contacting an interpreting service to arrange for an interpreter to be present on the day of the appointment or to arrange a video teleconference through an interpreting service during the time of the visit. Communication styles will vary among deaf patients based on several factors including the age of onset of the deafness—prelingual (before the patient started talking) versus postlingual (after the patient started talking), the educational background of the patient, current age of the patient, gender of the patient, and the patient’s interest level. Some deaf patients are able to use and comprehend sign language, read lips, and read written materials, while others will only be able to communicate through the services of an interpreter. Just as there are different spoken languages from region to region, there are also different kinds of sign language. The most common sign language used in the United States and parts of Canada is American Sign Language (ASL). ASL is a distinct language for the deaf and is considered the native language of the deaf. It is not English translated into different gestures and finger movements, which is why some deaf patients have difficulty when reading written material. Other types of sign languages common in the United States include: ❖ Signed Exact English (SEE): This form of signing codes English words into a visual form.
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❖ Signed English: Similar to SEE but often borrows vocabulary terms from ASL. This language is more similar to ASL than SEE. ❖ Conceptually Accurate Signed English (CASE): Formerly pidgin signed English (PSE), this system uses ASL conceptual signs but in English word order. The medical assistant should ask patients which form of sign language they feel most comfortable with and arrange for the right interpreter. Most interpreters are able to adapt to the patient’s specific language needs. The following list provides some tips that can be useful when working with an interpreter: ❖ Set the room up in a triangular pattern. The medical assistant’s chair should be beside the interpreter’s chair and the patient should be centered across from the medical assistant and interpreter (Figure 8-9). ❖ Look and speak directly to the patient, not the interpreter, while communicating. For example, say to the patient, “What brings you to the office today?” but don’t say to the interpreter, “Ask the patient the purpose of today’s office visit.” ❖ Give patients time to think about their response and make certain that they are completely finished with their response before asking a new question.
FIGURE 8-9 The proper way to set up a room when using an interpreter for a deaf patient. Notice that the patient can see both the medical assistant and the interpreter. This allows the deaf patient to observe both the parties simultaneously.
Refer to Procedure 8-3, Effectively Communicate with Hearing Impaired or Deaf Patients When an Interpreter Is Present, for a complete procedure.
Working with Patients Who Speech Read Patients who speech read usually have some hearing, although it may be limited. Speech reading (also known as reading lips) is hard to master and even the best speech readers can only interpret about 30% of the words formed with the lips during a verbal encounter. Because of this, speech readers use other cues to assist them including tongue movement, cheek positioning, throat positioning, and facial gestures. They will also look for other body gestures to assist them in the communication process. The following list provides other helpful tips when working with speech-reading patients: ❖ Choose a room that is quiet, well lit, and glare free. ❖ Position yourself directly across from the patient at the same level as the patient. When possible, lighting should be angled toward your face. ❖ Do not turn away from the patient when speaking, which can occur as you write or reach for something. ❖ Do not chew gum. ❖ When the patient doesn’t understand a statement that you have made, try rephrasing it instead of repeating it. ❖ Use gestures and hand cues to assist in the communication process. ❖ Do not yell and do not slow down or overenunciate your words. Speech readers read speech at a normal speaking rate. ❖ Make certain that the patient understands what is stated by having the patient repeat the information back to you. Refer to Procedure 8-4, Effectively Communicate with a Hearing Impaired or Deaf Patient That Speech Reads, for a complete procedure.
Hearing Guide Dogs Just as some blind patients have guide dogs, some deaf patients have “hearing guide dogs,” also known as “signal dogs.” These dogs are trained to alert teammates of special sounds and will physically lead them to the sound. Knocks on the door, door bell rings, telephone rings, and the sounds of a honking car are just a few of the sounds the dog is trained to respond to. Deaf people that typically use hearing guide dogs are those who became deaf later in life. Signal dogs generally wear bright orange leashes when they are working and should not be distracted.
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Working with Older Adults The average life expectancy today is somewhere around the age of 75. According to the U.S. Census, 34 million Americans today are above the age of 65 and that number is expected to double by the year 2030. Currently, 50% of the patients that that are seen in health care are senior adults. Age can be deceiving. Just because a person is over a certain age does not mean that the individual will have a hearing or visual impairment or will be in failing health. Seniors want to be respected and included in health care decisions. They do not want to be patronized or treated as though they are children. They expect quality health care and want to know that the professionals caring for them are knowledgeable, respectful, and considerate. Now more than ever, those working in health care must have an understanding of how to better serve their senior patients. This chapter will focus on cultural and communication issues which affect the senior patient. Chapter 18 discusses the physiological, mental, and emotional effects of aging.
What Seniors Are Thinking Regardless of the patient’s health status, some philosophies or thought patterns are relatively common among persons over the age of 65. Again, not all seniors will feel the same, but as a culture, there may be some similarities. Knowing these commonalities will help the medical assistant use communication techniques that are pleasing to the patient and avoid communication anomalies that may cause stress. The following list depicts some of those views: ❖ Most seniors prefer to be addressed as Mr. or Mrs. _________, but always ask patients how they would like to be addressed for future encounters. ❖ Professional appearance of the medical staff is important to many seniors. They will quite
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often perform a head-to-toe appearance inventory, checking hair, uniform, nails, and shoes for cleanliness. They are often distressed by body piercings and tattoos in “unusual” places and may even request that someone else draw their blood or give their injection in such cases. ❖ Professional behavior is paramount in the eyes of most seniors. They may become quite disturbed when they observe the medical assistant talking and joking with coworkers instead of appearing busy with work. They appreciate compliments and nice gestures but usually do not like to be referred to as Hon, Honey, Sweetie, or Pops. ❖ Seniors usually detest being spoken down to or being patronized. ❖ Most seniors have a playful side and enjoy a bit of humor from time to time, but remember there is a time and place for everything.
Physical Aspects of Working with Senior Patients As the body ages, the muscles and skin become much more sensitive. The medical assistant must be careful when assisting senior patients onto tables or into chairs. Assisting a senior patient onto an examination table can be quite traumatic for both the patient and medical assistant (Figure 8-10). The patient may say things like “You are so rough” or “You are not very gentle.” The patient’s skin is sensitive and even though you don’t feel like you are exerting a great deal of pressure, you
FIGURE 8-10 Minute amounts of pressure can be uncomfortable or painful to senior patients.
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may be exerting more force than you realize. Ask the patient to tell you if you do anything to make them feel uncomfortable or cause pain. Check your thermostats on a regular basis and make certain that they are at a comfortable setting for the patient. Give the patient a drape or a blanket that can be placed over the lap until the provider examines the patient. Treat the patient the way that you would want others to treat your own family members.
The Mental Outlook of Senior Patients Many seniors suffer from loneliness and depression. This is especially true for those seniors that are widows or widowers. Their loneliness may be due to a lack of attention from family members and friends. To these seniors, going to the physician may be more of a social event than a health assessment. Seniors may view the office staff as their extended family and unknowingly monopolize staff members’ time. The medical assistant should be respectful and listen whenever time permits. The health care worker may gently pat the patient on the shoulder or squeeze the patient’s hand to demonstrate a caring attitude. Medical assistants should alert the physician when they observe signs of dementia or depression. Often it is easier for the patient to open up to the medical assistant rather than the physician. The patient should be encouraged to follow treatment plans and to take medication the way it is prescribed. Demonstrating a caring attitude toward patients will help patients feel better about themselves and will encourage compliance on their part.
❖ Offer assistance with the removal and putting on of clothing. ❖ Ask the patient about the temperature of the room. If you can’t adjust the thermostat, give the patient a warm blanket or sheet to cover up with. ❖ Warm up anything that will touch the patient’s skin, such as your stethoscope, speculums, or other items. ❖ Give patients an opportunity to participate in their health care by saying things like, “Do you have a preference as to which arm I use?” ❖ Follow through when you say that you are going to do something for the patient. ❖ When distributing reading materials, make certain that the patient has plenty of light to assist with vision. ❖ End the encounter with a little therapeutic touching. Many seniors are starving for a little affection. Try rubbing the patient’s shoulder, patting the patient’s hand, or extending a little hug at the end of the visit. ❖ Offer to assist the patient to the reception room or car if the patient is struggling.
Working with the Pediatric Patient Working with pediatric patients can be entertaining, but may also present unique challenges (Figure 8-11). Pediatric offices are usually fast-paced, which means that the office sees a high volume of patients in a short amount of time.
Tips for Improving Care for Senior Patients Caring for seniors may present some challenges, but overall it is quite rewarding. The best thing to do for senior patients is to show them that they are valued not just as patients but as individuals. The following is a list of tips that can improve communications with senior patients: ❖ Address them using their last name. Ask them what they prefer to be called for the remainder of the visit and for future encounters. ❖ If the patient is hearing impaired, give the patient time to adjust the hearing aid and sit on the side of the patient in which the patient’s ear has the best hearing. ❖ Take a few moments to learn about the patient’s personal life before the interview begins. If you know about a recent event that occurred between the last visit and the current visit, such as a wedding or a birthday, inquire about it.
FIGURE 8-11 The medical assistant works to gain the child’s acceptance by stooping down to his level and using lots of expressions.
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Children are usually fun to observe and to carry on a conversation with but generally they have no concept of a schedule. Therefore, the medical assistant must learn how to gain the child’s cooperation early during the visit to avoid running behind schedule. Infants are usually easy to prepare for examinations because they are generally passive and used to being handled. Preschoolers and young children, on the other hand, are not always as cooperative and may demonstrate resistance along the way. By the time children reach the preschool age, they are accustomed to the usual events of an office visit and may be anxious. The child may scream or hold on to the mother’s leg, and in rare cases, even slap, kick, or bite the medical assistant. The medical assistant must learn effective communication techniques to promote cooperation with pediatric patients and their parents. This chapter will list communication guidelines for working with pediatric patients. Chapter 19 focuses on the specific needs of the pediatric patient and their overall health care.
General Guidelines for Working with Younger Children Caregivers working in pediatric offices must be patient and should genuinely enjoy working with children. Children are quite intuitive and can discern when adults do not care for them. They may be fearful and become frightened by nonthreatening procedures such as being weighed or having their blood pressure measured. Children may also be playful and want to play with the equipment that is being used such as the stethoscope. They may prefer to dance and sing when their vision is tested instead of reading the symbols on the eye chart. The following list provides tips on how to effectively communicate with young children: ❖ Involve the child in the discussion. ❖ Use terms that the child understands. ❖ Start the discussion out by asking the child about nonhealth-related items such as school, pets, or siblings. This will help the child to gain trust in you. ❖ Gently and in a nonthreatening manner, explain to the child what you are going to do and why you are going to do it. Ask the child to assist you whenever possible. Use phrases such as the following: “Adam, I am going to take your blood pressure to make certain that your heart is working okay. Before I do, can you point to where the heart is located on this little bear? Would you like to listen to the bear’s heart before we get started?” (Figure 8-12).
FIGURE 8-12 Allowing a child to investigate the equipment before you use it is a good way to gain cooperation from the child.
❖ End every visit with some kind of prize such as stickers, a cartoon adhesive bandage, or other items that promote a positive attitude.
Performing Invasive Procedures on a Young Child The following is a list of tips for performing invasive procedures on pediatric patients: ❖ Never lie to a child. Be honest and upfront. Explain what you are going to do, such as, “Hello Johnny! I need to give you some medicine in your leg today so you will start feeling better.” ❖ To minimize the child’s anxiety, keep the needle out of the child’s view. ❖ Children may feel more secure holding on to their mom or dad or sitting on their parent’s lap during invasive procedures; however, do not involve parents who appear to be apprehensive.
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❖ Provide something for the child to squeeze during the procedure such as a little stuffed animal or large sponge ball. It is best if the toy is something that he can take with him so that he doesn’t have to give it up at the end of the procedure. Make certain the toy is safe for the child’s age range. ❖ Work quickly. The longer the procedure takes, the more traumatic it is for the child. ❖ Praise the child and offer a prize for good behavior, such as, “Johnny, you did so good today that I am going to let you choose something special from the toy chest.”
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FI E L D S M A R T S Before performing visual acuity testing on a young child, start by having the child stand close to the chart. Ask the child to identify the shapes, or explain which way the legs are positioned on the “Big E Chart.” This will establish that the patient can identify the objects correctly and will stimulate more involvement from the child once the testing begins.
Performing Noninvasive Tests on a Young Child Start out by explaining the procedure to the child. Make certain that the child has a good grasp of the procedure by doing some practice testing first. Once you are certain that the child understands the procedure, you may begin the testing.
Working with Physically Disabled Patients A physical disability refers to an impairment that restricts or prevents normal functioning of a particular limb or group of limbs. The condition may be temporary or it may be permanent. The medical assistant may need to make special accommodations for these types of patients. If the disability involves the upper extremities, the medical assistant may need to offer the patient assistance with writing, disrobing, and dressing. If the disability involves the lower limbs, the patient may be using some type of assisted device such as a cane, walker, or crutches. If the disability involves both lower limbs, the patient may need the assistance of a wheelchair.
Hygiene Issues and the Physically Disabled Patient Physical disabilities that involve casting may impair the patient’s ability to properly shower or bathe. If the patient’s hand or arm is fractured, not only can she not
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F IEL D S M A R T S Some offices use distraction techniques while performing invasive procedures. You may give the child a noisemaker to blow until the procedure is over. Or the child can count as loud as she can from 1 to 10.
submerge her cast in water, but she does not have the mechanical ability to properly wash herself, especially if the affected limb involves her dominant hand. If the lower limbs are involved, it may be difficult for the patient to get into a tub or to go the store to buy soap products for cleansing purposes. The patient may feel embarrassed when she comes to the office and even apologize at the beginning of the appointment for her “poor hygiene.” The medical assistant must never make the patient feel uncomfortable by making faces or comments that are derogatory toward the patient. Nor should the medical assistant make derogatory comments about a patient’s hygiene to other coworkers. Those working in health care should be kind and compassionate and put themselves in the place of their patients.
General Guidelines for Working with Physically Disabled Patients It is important to know that not everyone with a physical disability will need assistance. Many disabled patients, especially those with permanent disabilities, are independent and are perfectly capable of getting around. Others, however, will welcome assistance. Some basic rules for working with physically disabled patients are: ❖ Prepare the room ahead of time. Gather supplies or equipment that will assist in the patient’s overall comfort. ❖ Always offer assistance, but do not insist on providing assistance. ❖ Question the patient about home needs. Some patients may not know that there are special devices that can assist them with daily tasks such as bathing, eating, and opening cabinet doors. ❖ Always reflect a caring attitude.
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Assisting Patients in Wheelchairs The following are guidelines for working with patients in wheelchairs: ❖ Prepare the examination room for the wheelchair and clear anything in the path between the reception room and examination room that could impair the patient’s ability to maneuver the wheelchair around it. ❖ Always offer to wheel the patient from the reception room to the examination room. This also provides the patient or caregiver rest from operating the wheelchair. ❖ Be careful not to run the wheelchair into walls or doors. ❖ When the patient is unable to walk, check with the health care provider to see if the patient can remain in the wheelchair for the examination. There are many procedures that can be performed directly from the wheelchair. ❖ When necessary, offer the patient assistance with clothing removal and re-dressing. ❖ Offer to wheel the chair out to the patient’s vehicle. This will assist the caregiver and demonstrate a caring attitude to the patient and patient’s family. Chapter 21 lists the specific procedures for assisting patients from the wheelchair to the examination table and back again.
Working with Patients Who Are Mentally Impaired The Substance Abuse and Mental Health Services Administration (SAMHSA), a division of the HHS, defines mental health as “how people look at themselves, their lives, and the other people in their lives; evaluate their challenges and problems; and explore choices.” Mental illness is a disorder that disrupts the person’s ability to think, feel, and relate to others. Examples of mental illness include: ❖ Major depression ❖ Bipolar disease ❖ Certain anxiety disorders (panic disorders, obsessive compulsive disorder, and posttraumatic stress disorders) ❖ Schizophrenia Most mental illnesses are believed to be organic in nature caused by neurochemical imbalances. These conditions are usually treated with psychotherapy and psychiatric medications. Some experts believe that
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lifestyle changes in combination with social and environmental support can also assist those suffering from various types of mental illness. The term mental impairment refers to a condition or illness that impairs the mind’s ability to process information in a “normal” fashion. Impairment may be brought on by a mental illness, brain damage, or senility. The National Institute of Mental Health (NIMH) estimates that one in five adults suffer from a diagnosable mental disorder. The degree or type of impairment will determine the amount of extra intervention that is necessary to assist these patients.
Guidelines for Working with Patients with Mental Disorders or Impairments The first step toward working with patients who suffer from mental disorders or impairments is to drop any preconceived notions that are negative. These patients should not be thought of as “crazed” or “mad.” People who suffer from mental impairment come from all walks of life and quite often are bright. As stated earlier, many of these disorders are due to an imbalance of various neurochemicals. Like any other disease, sometimes the patient responds well to treatment; however, in other cases, the physician may have to experiment with quite a few psychotropic medications combined with various forms of psychotherapy before discovering the right treatment. Other tips for working with mentally impaired patients include: ❖ Demonstrate compassion and empathy toward the patient. ❖ Understand that each condition has its own array of symptoms, emotional struggles, and communication challenges. ❖ Avoid talking down to the patient. ❖ Be respectful and treat the patient with the same level of dignity as other patients. ❖ Direct your questions toward the patient whenever possible. ❖ Never laugh or snicker at a comment that appears to be nonsensical or irrational.
Guidelines for Working with Patients Who Are Mentally Challenged Some patients with mental impairments may also be mentally challenged. When a patient is diagnosed as being mentally challenged, it means that the brain functions at a subnormal intellectual level. Patients who are mentally retarded are sometimes referred to as
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mentally challenged or mentally deficient. The causes of mental retardation include congenital defects, brain injuries, and disease. These patients may find it difficult to think in a clear, organized manner and may struggle with instructions that are abstract or that constitute multiple directions. Guidelines for working with these patients include: ❖ Question caregivers to learn more about the patient’s level of understanding. ❖ Use language that can be easily understood by the patient. ❖ Give simple instructions that only involve one direction at a time. ❖ Realize that directions may need to be given several times. ❖ Do not become agitated if the patient refuses to follow instructions. Instead, give the patient a break before trying the procedure again.
Caring for Patients with Dementia Dementia is a deterioration of intellectual functioning that affects the patient’s memory and ability to concentrate. The patient’s ability to react and judge is severely impaired, and the patient may suffer from personality changes as a result of the disease. Dementia usually progresses with time, forcing the caregiver to place the patient into an extended care facility. Approximately 2.5 million people are diagnosed with dementia each year and that number is rapidly increasing due to longer life spans. Contributing factors of dementia include Alzheimer’s disease, alcoholism, endocrine and metabolic disturbances, traumatic brain injuries, seizure disorders, nutritional deficiencies, and immunological disorders. Tips for working with dementia patients include: ❖ Be empathetic toward both the patient and the caregiver. Caregivers often become ill themselves from the physical and emotional strain of caring for the patient. After addressing the patient’s needs, address the needs of the caregiver preferably in an area away from the patient. ❖ Simplify instructions. Patients with dementia often experience difficulties with the smallest of tasks. Keeping the instructions simple will help to prevent the patient from becoming agitated. Break down procedures into step-by-step directions. For example, “Mr. Jones, I need to weigh you today so the first thing that I need you to do is to remove
your shoes. . . . Great. . . . Now I need you to follow me to the scales. . . . Okay Mr. Jones, I need you to step up onto the scales.” ❖ Ask the patient’s caregiver for assistance when the communication process appears to be in a state of decline. ❖ Avoid laughing at comments that appear nonsensical or irrational. Remember that the patient lives in a different world than you do and laughter may provoke the patient to become angry or feel inferior. ❖ Above all, practice patience! Because dementia patients take more time, ask your coworkers to watch your rooms ahead of time so that you can give the patient and caregiver your full attention. In advanced cases of dementia, the patient may drift in and out of various time periods or may even think that they are somewhere other than the provider’s office. They may not recognize you even though you have been caring for them for several years or they may think that you are someone else such as a friend or a relative. Try to gently correct the patient, but if the patient appears to become more agitated as a result of the correction, you may want to look to the caregiver for cues. Some of the most recent research states that in some cases, it is better to step into the world of the patient, rather than to force the patient into reality.
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C R I T I C A L T H I N K I NG CHALLENGE An 83-year-old male patient with dementia appears confused by instructions that you give him for urine collection. His caregiver, his daughter, also tries to explain the procedure, but the patient just doesn’t understand. The daughter volunteers to help her father, but he quickly refuses the daughter’s assistance. 1. What are some things that you can do to help the patient with the instructions? 2. What might be an alternative if the patient refuses or just never comprehends the instructions?
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PROCEDURE 8-1 Effectively Communicate with Patients from Different Cultures Objective: To use effective communication techniques when working with patients from other cultures.
Equipment/Supplies: ❖ Patient’s chart ❖ Pen PROCEDURAL STEPS
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1. Prepare the interview area. The interview area should be private, comfortable, and free of distractions. The furniture should be set up to accommodate the patient and anyone who may be with the patient, including an interpreter. The medical assistant’s chair should be set up at least 4 to 12 feet directly across from the patient and interpreter if present.
Properly preparing the room will make the patient feel more comfortable and more receptive to answering the questions.
2. If you are not the same gender as the patient, ask the patient if she would prefer to have a medical assistant of the same gender.
This will help the patient and possibly the patient’s spouse to feel more comfortable. Patients from Middle Eastern populations are especially concerned about this.
3. Identify yourself, list your title, and identify the patient. If you are uncertain how to properly pronounce the patient’s name, ask the patient for the proper pronunciation. Write the phonetic spelling somewhere in the chart.
Foreign names are quite often difficult for English speakers to pronounce. Asking the patient for clarification communicates respect toward the patient.
4. Ask the patient to introduce any family members that are present.
An introduction assists in building trust with family members and acknowledges their role in the patient’s health care.
5. Ask the patient a little bit about her family or career.
This type of conversation can help the family feel more at ease and gives the medical assistant an opportunity to check the patient’s English skills or the English skills of the family member who will be performing the interpreting.
6. If the patient has limited English and a professional interpreter is not present, give the patient written materials that explain the patient’s right to a professional interpreter. If the patient states that a family member will be performing the interpreting, explain to the family member the importance of accurate interpreting.
Patients may not know that interpreting is available or may be fearful about using an interpreter. They may not want to hurt a loved one’s feelings or may be fearful about admitting that they do not want the family member present. Making the suggestion to have a professional interpreter takes the patient off of the hook with the family member.
7. Ask the patient to explain the goals for today’s visit.
Setting goals sets the tone for the visit. It provides an agenda for the patient and allows the patient to express personal goals as well. continues
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8. Speak clearly and avoid using any slang or medical jargon. Talk directly to the patient even if an interpreter is present. Avoid using many gestures as some American gestures may be considered obscene in some cultures.
Using medical terms or slang could cause the interpreter to become confused. Use common everyday words whenever possible.
9. Have the patient repeat back any instructions to ensure that the patient understands the information.
Comprehension promotes compliance on the patient’s part.
10. Direct and demonstrate which clothes need to be removed and explain why they need to be removed. Provide the patient with items such as gowns, sheets, or drapes to help ensure modesty.
Modesty is very important to most patients, but in particular to people from specific cultures. The more you can assist in protecting the patient’s modesty, the more cooperative the patient will be.
11. Thank the patient and family members for their cooperation and let them know that the physician will be in momentarily. 12. Document the visit and record and explain any paperwork that was given to the patient, as well as if an interpreter was present.
Documenting that an interpreter was present illustrates that the office did everything possible to promote effective communication.
DOCUMENTATION EXAMPLE:
03-12-XX 1300
Pt. here for immigration physical today. Arabic Translator Amani Barakat was present and translated during the interview process. Pt. has no current physical concerns. See attached medical history form. Theresa Pugh, CMA (AAMA)
PROCEDURE 8-2 Effectively Communicate with Sight Impaired or Blind Patients Objective: To assist a patient that is visually impaired or blind by using effective communication techniques.
Equipment/Supplies: ❖ Patient’s chart ❖ Pen PROCEDURAL STEPS 1. Prepare the patient’s room by clearing anything that could cause the patient to trip or fall. Also prepare the walkway from the reception room to the examination room to make certain that it is free of any obstacles.
RATIONALE This is for safety purposes.
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2. When you go into the reception room, gently call out the patient’s name and tell her that you are ready to assist her back to the room. Do not shake the patient’s hand unless the patient extends her hand first.
You do not want to startle the patient. A gentle hello, followed by the patient’s name will let the patient know that you are nearby.
3. Identify yourself and state your title.
This allows the patient to place a name with the voice and tells the patient that you have authority to take them back to the room.
4. If the patient has a guide dog, do not touch or talk to the guide dog while the harness is on. Have the patient and the dog follow you back to the room.
Talking to the dog or touching the dog can distract the dog, making it difficult for the owner to get the dog to perform its duties.
5. If the patient does not have a guide dog, ask the patient if she would like to have sighted guide assistance.
Sighted guide assistance is a nice gesture to show the patient that you would like to help them. Do not insist on sighted guide assistance.
6. If the patient wants sighted guide assistance, ask the patient which side she prefers to be assisted on.
Some patients feel more comfortable being assisted on one side or the other.
7. Position yourself on the side that the patient indicates and allow the patient to grasp your arm, usually just above the elbow (Figure 8-13).
Allowing the patient to grasp your arm prevents you from dragging the patient.
8. Walk with your arm down to the side about a half step in front of the patient toward the inside of the patient.
This makes it easier to feel your body movements and allows the patient to anticipate the next move.
9. Warn the patient about the surroundings and any obstacles, such as a doorway, an elevator, or a staircase.
FIGURE 8-13 When providing sighted guide assistance, allow the patient to grasp your arm.
This gives the patient time to prepare for the change in elevation or width.
10. Approach seating in a forward motion. Describe the type of seating that the patient will be placed in, such as a low sofa, upright chair, or an armchair.
This allows the patient the ability to assess the seating so that she can judge how far down she will need to bend when sitting down.
11. Walk the patient to the front of the chair, allowing her knees to just gently touch the front of the cushion or seat.
This assists the patient in knowing the height of the chair.
12. Place the patient’s hand on the arm of the chair and allow the patient to finish seating herself.
Grasping the arm of the chair will assist with security as the patient sits down.
13. Interview the patient in the way that you would any other patient. 14. Lay out all gowns and drapes beside the patient. Let her know their exact location before leaving. Ask the patient if she needs any assistance getting dressed.
This helps the patient be more at ease with her new surroundings.
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15. When performing procedures, alert the patient to every step before you perform it.
This ensures that she is not startled when you touch her.
16. Notify the patient that you are leaving and tell the patient that the physician will knock before entering.
This lets the patient know that she will be temporarily alone.
PROCEDURE 8-3 Effectively Communicate with Hearing Impaired or Deaf Patients When an Interpreter Is Present Objective: To assist a patient who is hearing impaired or deaf by using effective communication techniques.
Equipment/Supplies: ❖ Patient’s chart ❖ Pen PROCEDURAL STEPS 1. Set the chairs up in a triangular pattern. The patient’s chair should be centered and directly across from both the medical assistant and interpreter.
RATIONALE The triangular pattern will allow the patient to look at both the interpreter and the medical assistant without turning her head.
2. Ask the interpreter to introduce herself.
3. Look directly at the patient during the communication encounter, not at the interpreter. Keep in mind, however, that the patient will be focusing on the interpreter.
Many deaf patients can also do minimal lip reading. It also shows the patient that she is your focus, not the interpreter.
4. Talk at a normal rate of speed.
Interpreters and speech readers are trained to interpret at a normal conversation rate.
5. Ask the patient to repeat back any instructions.
This ensures effective communication and comprehension on the part of the patient.
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6. Give the patient written instructions to take home.
This is a nice reference item that the patient can refer to later.
7. Thank both the patient and interpreter for their participation. If the patient indicates that she really liked this interpreter, make a note of it in the patient’s chart.
It is important to use interpreters that patients trust and understand.
8. Document the encounter and state that the interpreter was present.
Documenting that an interpreter was present illustrates that the office did everything possible to promote effective communication.
DOCUMENTATION EXAMPLE:
09-15-XX 1400
Pt. here to discuss lab results from the last visit. Cheryl Taylor, interpreter from Medical Interpreting, Inc., was present for today’s visit. Pt. still c/o of joint pain and fatigue. No changes in medications. Michael Allen, CMA (AAMA)
PROCEDURE 8-4 Effectively Communicate with a Hearing Impaired or Deaf Patient Who Speech Reads Objective: To use effective communication techniques for patients who are hearing impaired and who can speech read.
Equipment/Supplies: ❖ Patient’s chart ❖ Pen PROCEDURAL STEPS
RATIONALE
1. Prepare the interview area. Choose a quiet room that is well lit and glare free. Lighting should point toward your face.
Choosing a room that is well lit and glare free will assist the patient in viewing your lips and facial cues.
2. Position yourself directly across from the patient at the same level as the patient.
This will provide a good angle for the patient to speech read. Remember that the patient will be viewing your throat, tongue, and cheeks and will also be looking at your expressions.
3. Speak at a normal rate of speed. Do not turn your head away when speaking to the patient.
People who speech read are trained to read speech at a normal talking rate. Speeding up or slowing down or over enunciating your words will distort what is being stated. continues
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4. Use gestures, hand cues, and written materials to assist in the communication process.
These cues and written items will assist with effective communication.
5. When the patient doesn’t understand a statement that you have made, try rephrasing it instead of repeating it.
Repeating the same sentence will probably not remedy the problem, so try rephrasing with different words. The patient may be able to read the next phrase more easily than the first phrase.
6. Have the patient communicate back to you any instructions that you have given. This may be through gestures, speaking, or writing.
You need to ascertain that the patient comprehended any instructions that were given.
Chapter Summary Learning how to effectively communicate with patients is vitally important in order to provide the patient with the best care possible. Good communication skills assist in obtaining important information that can be used to properly diagnosis and treat the patient. Each patient has his own array of social, physical, and emotional challenges. Medical assistants who learn techniques to accommodate all patients, regardless of their unique set of needs, will earn greater respect from their patients, coworkers and supervisors.
FIELD APPLICATION CHALLENGE Mrs. Adams, a blind patient, has an appointment to have some blood work performed today. She is accompanied by her guide dog. You are ready to take the patient back to a blood drawing area. 1. How should you approach the patient in the reception area?
dog to lead her back to the blood drawing area? Why or why not? 3. What should you do if you see people in the reception area trying to pet and talk to the dog? 4. Will the patient need sighted guide assistance?
2. Your office has a policy that no pets are allowed in the facility. Will you permit her to allow the
Chapter Assessment 1. Examples of special needs patients include all but which of the following? a. Blind patients b. Deaf patients c. Culturally diverse patients d. Patients who work in health care
2. Which of the following acts/laws make it mandatory for offices to provide auxiliary aids or services to ensure “effective communication”? a. Title l of the American Disabilities Act b. Title III of the American Disabilities Act c. HIPAA d. The Civil Rights Act
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3. When working with patients from other cultures, the medical assistant should: a. use lots of gestures to enhance what is being stated. b. ask the patient for the correct pronunciation of her name. c. insist that the patient remove clothing regardless of the patient’s modesty concerns. d. ask the patient about her religion to gain a better understanding of her beliefs. 4. Direct eye contact is considered disrespectful among: a. Westerners. b. Middle Easterners. c. Latin Americans. d. all the above. 5. Which culture emphasizes interdependence over independence? a. Western population b. Middle Eastern population c. Latin American population d. Asian population 6. When pediatric patients are to receive an invasive procedure, the medical assistant should do all but which of the following? a. Tell them that it probably will not hurt b. Be honest and tell them that they may feel some discomfort c. Give them something to hold during the procedure like a stuffed animal or ball d. Explain the purpose of the procedure 7. Patients with mental impairments should: a. be treated with respect and kindness. b. be addressed directly during the patient interview. c. be assessed to determine their ability to communicate. d. all of the above. 8. Which of the following is not a prerequisite to be considered a “qualified interpreter” under ADA guidelines? a. Must be extremely fluent in the patient’s native language and English b. Must be properly trained to provide interpretation in a medical facility c. Must demonstrate competence in medical interpreting d. Must be a U.S. citizen
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Web Activities 1. Go to the Department of Labor Web site (www.dol .gov). Research information on this Web site and list four federal agencies that enforce the ADA rules besides the Department of Labor. 2. Enter the phrase “National Technical Institute for the Deaf” into a search engine. Bring up the home page of this Web site and read one of the articles under “Articles and Resources.” Write a half-page report on your findings. 3. Type the words “Alzheimer Association” into a search engine. Bring up the home page. Click on “Resources” and click on “Fact Sheets.” Print a fact sheet on Alzheimer’s disease. Share the information with your classmates.
CONNECTION Using your StudyWARE CD-ROM: ❖ Complete the Flash Cards activity for this chapter. ❖ Complete the Quiz for this chapter in Test Mode.
THE DVD LINK On your StudyWARE CD-ROM, go to the DVD Challenge for this chapter. View the DVD clip and respond to the following questions: 1. Do you feel that it was appropriate for the medical assistant to start the visit without the interpreter? What device did the medical assistant use to communicate until the interpreter arrived? 2. How were the chairs set up during the educational session? 3. When the medical assistant gave instructions, who was he looking at: the patient or interpreter? 4. Do you feel that the medical assistant had good rapport with the patient and achieved his educational instruction goals?
C H A P T E R
Patient Education
Essential Terms
Chapter Outline Adult Education Principles Settings and Procedures Tools for Education Communication Verbal Communication Nonverbal Communication Stimulating Patient Compliance
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Topics for Education Self-Examinations Screening Examinations Educating Patients about Their Medication Conducting Educational Sessions over the Telephone Identifying Community Resources for the Patient
Developmental Objectives After completing this chapter, you should be able to: 1. Correctly spell and define essential terms. 2. List five characteristics of an adult learner. 3. List and define six barriers that impede learning during the educational encounter. 4. Describe the desired environment for educational sessions. 5. Describe the different types of senses used during educational sessions and give examples of tools that can be used for each sense. 6. Describe three types of learners. 7. List and describe six different techniques that can be used to enhance learning and to help ascertain that the patient comprehends the material.
active listening adaptive questioning audio learner echoing empathy reassurance summarization tactile learner validation visual leaner
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ABHES
Provide Instruction for Health Maintenance and Disease Prevention
III.C.3.c.3.c
VI.A.1.a.7.c
Identify Community Resources That Will Assist the Patient
III.C.3.c.3.d
VI.A.1.a.3.e
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8. List examples of various topics for patient education. 9. Describe common educational topics presented over the phone. 10. List different types of community resources that are available in assisting patients with overall health and well-being and describe how to locate these resources.
Introduction The promotion of health involves not only treatment of pathologic disorders but also prevention of disease along with proper compliance of medical treatments. In order to make informed choices regarding the care of one’s own body, education is essential. The medical assistant will frequently be involved in providing education regarding prevention, treatment options, and protocols involved in health care. The highest level of patient education occurs when the health provider is cognizant of learning theories and strategies and has a basic understanding of educational principles. It is important to understand how different patient characteristics—such as gender, age, intellect, and state of well-being—contribute to the successfulness of the session. Environmental settings, communication skills, and educational tools impact the learning capacity of the patient and have a direct effect on patient compliance.
ADULT EDUCATION PRINCIPLES When providing patient education, it is important to understand the principles that are instrumental in teaching adults. Most education provided by the medical assistant will be to an adult—whether an adult patient, a parent of a pediatric patient, or an adult caregiver or spouse. Some basic theories regarding adult education include the following: ❖ Adults often seek out information, which assists in understanding and coping with disease and treatment. ❖ Increasing self-esteem is a strong motivator for the adult patient. ❖ Adults tend to integrate new information with past experiences and prior education. ❖ Adults tend to prefer self-directed education rather than group involvement. ❖ Adults prefer to set the pace for their learning, controlling start and stop times. ❖ A comfortable learning environment contributes to the successfulness of the session. Malcolm Knowles was a pioneer in theories of adult learning and identified some distinct characteristics of the adult learner. Table 9-1 presents these characteristics and provides examples of how they might apply to patient education. Patient motivation needs to be nurtured. A highly motivated patient is more likely to be a compliant patient. An adult’s interest in learning may have different
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TABLE 9-1 Characteristics of the Adult as a Learner According to Malcolm Knowles CHARACTERISTIC
HOW THIS MIGHT BE USED BY THE MEDICAL ASSISTANT IN PATIENT EDUCATION
Adults are autonomous.
The medical assistant must involve the patient in the learning process, rather than just supplying facts. Active participation is necessary for success.
Adults have much life experience.
It is important for the medical assistant to listen to the patient and incorporate previous learning into the educational process. Past experiences should be incorporated.
Adults are goal-oriented.
The medical assistant must clarify the importance of the education provided. Establishing attainable goals keeps the patient motivated and assists with compliance.
Adults are practical.
The patient education session must be useful for the patient.
Adults need respect.
An understanding of the educational background of the patient will prove helpful. It is important to remember that the patient is not a child, and the medical assistant is not superior to the patient. Respect improves any relationship between the health team member and the patient.
motivational forces; therefore, researching facts about the patient, such as occupation, family, and hobbies, will assist the medical assistant in getting the patient to buy in to what is being sold during the session. There are also barriers to education that must be considered. These include, but are not limited to: ❖ Time: Be certain there is enough time to allow for adequate instruction. Instruction may not be provided during the initial office visit. The medical assistant may need to schedule another visit to allow for ample time. ❖ Money: The patient may not have the financial means to include all of the practices taught. This must be considered when providing the instruction or plan of action. Perhaps a certain drug or procedure is not the most financially feasible Alternative protocols might need consideration.
TOOL BOX
F IEL D S M A R T S Be aware of your own biases, such as against obesity, smoking, or body piercing. Remain professional when providing patient education. Ask yourself, “Is this for me or for the patient?” If a patient is not ready or prepared for discussing or learning the educational content, the time spent may not be effective.
❖ Interest: If the patient has no interest in making the changes, instruction will be totally ineffective. ❖ Child care: If an unruly child is interrupting the educational session, the patient may lose interest, focus, or patience. Another time may need to be scheduled for highest compliance. ❖ Transportation: It may be difficult for the patient to obtain adequate transportation for future patient education. It may also be a problem to require a driver to stay longer than expected for education following a physical exam. These challenges need to be considered. Instruction over the phone, although not the best setting, might be a better alternative for the individual patient and situation.
TOOL BOX
C R I T I C A L T H I N K I NG CHALLENGE You are presenting an important educational session to the patient regarding cancer prevention and awareness. The patient’s mother and sister both died from ovarian cancer. The patient brought her four-year-old niece to the session. The niece continually interrupts the patient throughout the session. 1. What are some activities that you can institute to keep the four-year-old busy during the educational session?
PAT I E N T E D U C AT IO N
SETTINGS AND PROCEDURES The appropriate setting will enhance the success of the educational session (Figure 9-1). Considering the theories of learning in conjunction with the concept of adult education, the following guidelines will prove most effective: ❖ Provide a quiet, comfortable environment for the session. ❖ Make certain the amount of lighting is sufficient to read any literature or view any diagrams. ❖ Avoid any distractions (loud noises, odors, children, etc.). ❖ Have comfortable chairs all at the same level so eye contact can be maintained. ❖ Have all supplies, brochures, and paperwork prepared and ready prior to the encounter. ❖ If possible, have your phone and intercom temporarily quieted. Eliminate anything that creates the feeling that the patient is being rushed or infringing on the time of the educator. ❖ Based on the comfort of the patient, the relationship with the patient, and the type of education provided, the chairs should be positioned either with the desk between the medical assistant and the patient (more formal) or with the chairs alone facing each other (more casual and personal). Using a round table when there are multiple family members participating in the session allows everyone to see the presenter and each other.
Tools for Education Various tools may be utilized to enhance the educational process. Figure 9-2 illustrates some tools that might be incorporated into the educational setting. Combining
FIGURE 9-1 A quiet, well-lit room provides the best environment for patient education.
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TOOL BOX
H I PA A PAT R O L Be certain that any confidential information regarding other patients is not displayed or left in view of the patient. This includes any computer monitors displaying confidential information. If a computer is on the desk, the monitor should be directed away from the patient receiving instruction if it is not being used during the session.
verbal instructions along with written materials has proven to increase learning retention. The addition of diagrams will also enhance the learning process. The more senses used in learning, the more material will be retained (see Table 9-2). Even as a medical assistant may have a certain protocol for instruction of a specific topic, different environments and tools may need to be implemented due
FIGURE 9-2 Useful supplies needed for a patient education session
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TABLE 9-2 Using Senses in Patient Education SENSE
DISCUSSION
TOOLS
Hearing
Listening to instruction or directions. Descriptions of an educational topic are spoken to the patient.
Lecture or presentation CD Audio tapes
Vision
Looking at directions, instructions, or guidelines. Instructions are given in writing, including outlines, maps, or photos. Visual tools can be supplied for viewing at home to reinforce instruction.
Brochures DVDs PowerPoint Slides Photos Handouts Models Internet
Touch
Using the hands to feel or palpate something.
Models Actual body parts
Smell
The sense of smell is powerful, although not often used in patient education. It can be used for descriptive purposes, for example, to help describe symptoms such as “fruity breath.”
Taste
Another sense not often utilized in patient education. It may be used for descriptive purposes, for example, a salty taste to help diagnose cystic fibrosis.
Speech
Allow the patient to participate in the discussion. This is important in adult education. Patient input also indicates an understanding of the instructional material.
to challenges or limitations of the patient. If a patient is hearing-impaired, visual tools are best incorporated into the educational session. If the patient is deaf, an interpreter should be present to assist with communication. Touch may be used for patients with visual challenges. Patients may also have their own preferred styles for learning. Is the patient more abstract or concrete in thinking? Is the patient a visual learner (learns more by reading or looking at pictures), an audio learner (learns more by listening to information), or a tactile learner (learns most by touching, holding, or doing)? Does the patient view the session as a benefit or a punishment? These determinations may direct the path of instruction along with the most effective teaching aids. The patient’s level of education may also dictate the most appropriate tool for the most success. The native language of the speaker will also affect which materials will be beneficial. For example, for a Spanishspeaking patient who speaks little English, many tools are available in Spanish. Having an employee fluent in
Verbal contracts
the patient’s spoken language will assist in instruction, allow for questions, and help verify understanding of the material.
COMMUNICATION It is important to set the tone for communication at the start of the session. Begin each session by setting
TOOL BOX
FI E L D S M A R T S Motivation has been discussed as a significant part of adult education. Determine early in the session the level of motivation in the patient. Why does the patient want or need to receive the instruction? This will provide direction for a successful interaction.
PAT I E N T E D U C AT IO N
goals together regarding what each party wants to obtain from the session. Be respectful of the patient and acknowledge family members. Many times, family members will be more instrumental in patient compliance than the patient alone. This is especially relevant during dietary training sessions. If the patient’s spouse does all the cooking and the session is geared toward lowering the patient’s cholesterol, the spouse should be drawn into the session as well as the patient. If the session is related to wound care, the spouse may need to take ownership in caring for the wound due to its location or the patient’s inability to comprehend the instructions. Communicating effectively with the patient involves many skills, both verbal and nonverbal. Words alone do not always create the best scenario for communication. Often nonverbal methods of communication are the most effective for patient education, especially when teaching the patient specific procedures such as how to perform in-home glucose testing or how to care for a wound.
Verbal Communication Verbal communication generally refers to the spoken word. Some effective techniques that can assist in patient education and ascertaining that the patient understands the material include: 1. Adaptive questioning: This will include a variety of types of questions. They should draw the patient into the conversation, a key principle of adult education. The questions will allow the educator a chance to evaluate the patient’s understanding, and allow the patient to incorporate past experiences into the new learning process. 2. Echoing: This involves simple repetition of the material. This can promote further interaction and clarification. 3. Empathy: This is a way to identify the patient’s feelings and respond with understanding. Empathy is used to strengthen rapport with the patient. During education, this may be a way to evaluate the motivating forces in the patient’s life. 4. Validation: This means to let the patient know that his feelings are considered legitimate. Self-image is an important part of adult education. Validating the patient’s concerns opens the door for learning. 5. Reassurance: Reassuring a patient who is anxious helps alleviate stress. Learning is more successful in a stress-free situation. 6. Summarization: Summarizing the learning session serves two purposes. First, it restates the mate-
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rial that was given and learned. Second, it tells the patient that his input has been heard.
Nonverbal Communication Although verbal communication can be very effective, nonverbal communication is also an essential tool for increasing the level of education provided and received. Nonverbal cues include the use of body language, eye contact, and most importantly, active listening. Body positioning is important to consider in both the medical assistant and the patient. The medical assistant’s shoulders should squarely face the patient; this indicates that full attention is being given to the patient. The body should lean slightly toward the patient, without invading personal space. Based on the response of the patient, alterations may be needed for patient comfort. Active listening involves focusing on the information at hand. It is important not to let your mind wander to the next topic. Patient cues must be observed, including the emotional level during the interaction. This will direct the speed and course of the education. Active listening usually employs good eye contact. This draws the patient into the training session, again increasing patient understanding. Understanding the “whys” and “hows” of patient learning techniques, employing good communication skills, establishing an environment conducive to learning, and providing appropriate training and learning tools will increase the outcome of each individual educational session.
TOOL BOX
C R I T I C A L T H I N K I NG CHALLENGE You just finished a patient education session on hypertension with a 70-year-old patient who is a bit hard of hearing. He is alone and doesn’t appear to have a real interest in what you are presenting. 1. What may be contributing to the patient’s apparent lack of interest in the subject matter? 2. What techniques can you use to ensure that the patient comprehends the information?
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STIMULATING PATIENT COMPLIANCE In order for the session to be successful, the patient will need to both understand and comply with instructions given during the session. Some tips for patient compliance include the following: ❖ Be a good role model. For example, if you are conducting a session on smoking cessation and you smell like cigarettes, it is going to be difficult to convince the patient to stop smoking. ❖ Include family members in the session (Figure 9-3). ❖ Look for indications that the patient understands and agrees with the material being presented. This should be assessed several times throughout the session. Don’t wait until the session is almost over to determine that the patient doesn’t understand. Have checkpoints along the way. ❖ Have the patient repeat back the information at the conclusion of the session. ❖ Follow up each session with written materials.
FIGURE 9-3 It is important to include in the educational sessions family members who can help to clarify information when the patient returns home.
❖ With the provider’s permission, give the patient supplies that will help with compliance (for instance, bandaging materials, drug samples, etc.). ❖ One to two days following the session, call the patient to see how things are going and to determine if the patient has any additional questions. ❖ During follow-up sessions, acknowledge patient compliance, and tactfully question noncompliance.
TOPICS FOR EDUCATION Many areas of medicine require patient education in order to provide the highest standard of care. The number of possible topics is vast. Some common topics for patient education include diabetes management, heart health, prevention and management of osteoporosis, and smoking cessation. The medical assistant should develop a teaching style that he is comfortable with, as well as one that can be adapted to the individual needs of the patient. Instructional material may be gathered through different organizations such as the American Diabetes Association or the National Alzheimer’s Association. The Internet provides hundreds of resources on popular topics, including downloadable brochures, animations, and interactive Web sites. Medical and pharmaceutical representatives often provide great teaching tools in the form of teaching models, DVDs, and wall charts. Medical assistants may also be called upon to develop instructional handouts and brochures for common topics within the practice where they are employed. This text provides numerous educational tool boxes that will assist in patient education.
TOOL BOX
E M R A P P L I C AT I O N Many EMR vendors integrate educational materials within their products. The medical assistant can bring the materials up on the screen during the session and print them for later review. Because these forms are computerized, they can easily be sent to the patient via e-mail as well. Practices that offer patients access to online portals may include an education tab where patients can go to view video clips, download brochures, or learn how to participate in patient Webinars.
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Self-Examinations Self-examinations are completed by the patient. The medical assistant must provide information for selfexaminations so the techniques will be performed accurately. Examples of self-examinations are breast and testicular exams. These are common early-detection examinations, essential for discovering masses, lumps, and other abnormalities that may indicate the need for further evaluation. Refer to Chapters 17 and 18 for information about breast and testicular self-exams.
Screening Examinations Several examinations are performed by the health provider to detect specific health problems. Schedules are developed to designate when these exams should be performed in order to find and remedy problems early. The medical assistant will educate the patient as to the suggested schedule for the exam, the procedure involved, and the patient preparation for a successful exam.
Educating Patients about Their Medication Educating patients on how to take their medications is one of the most frequent topics for health education. In order for the medical assistant to be a good educator, he must do some research on the medication before presenting the session. Information that should be acquired includes the following: ❖ ❖ ❖ ❖ ❖
The classification and use of the drug The directions for taking the drug Common side effects of the drug Contraindications for not using the drug Economical information (Knowing the economical resources of your patient will help in determining if compliance is even an option. When patients are limited in their funds, talk to the provider and drug company representatives to determine if there are any workable solutions.)
After the educational session, the medical assistant must ask the patient to repeat back the information and document the session in the patient’s chart. Figure 9-4 illustrates a medical assistant providing instruction for a patient about a new drug.
CONDUCTING EDUCATIONAL SESSIONS OVER THE TELEPHONE There are times when education will need to be performed over the phone. This is particularly relevant
FIGURE 9-4 The medical assistant gives a complete explanation of new medication to the patient and her daughter, along with thorough directions on how the medication is to be taken.
when there is a change in the patient’s medication or when particular lab results are outside the normal range. The provider will usually write specific instructions on the progress note or lab form identifying educational goals that should be discussed with the patient. Examples of educational topics that may take place over the phone include: ❖ The introduction of a new medication or a change in the way the patient is taking current medication ❖ Special dietary changes due to an abnormal lab result (such as elevated lipids or glucose) ❖ Instructions for the patient to see a specialist, dietician, or to have specific testing Communication skills are even more important when speaking over the phone because facial expressions and body language cannot be seen. Always have the patient repeat information to ascertain that he understands the information. Encourage the patient to obtain a pen and piece of paper at the beginning of the call and to write out the instructions. If the patient has access to e-mail, it may be beneficial to send the patient electronic instructions prior to placing the call. Then the patient can concentrate on listening to the instructions while reading the information and will not need to worry about writing the instructions.
IDENTIFYING COMMUNITY RESOURCES FOR THE PATIENT There are times when the patient needs more than just education to improve their health and overall wellbeing. Patients may have physical, health, or financial constraints that limit their ability to comply with
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treatment plans. In such cases, the medical assistant may need to assist the patient in obtaining resources necessary for improving health and the quality of life. At times, the patient may benefit from a support group. Support groups are especially useful for patients that have been diagnosed with a disease or condition that will greatly impact the patient’s lifestyle or mental outlook. The medical office should have a listing of community resources that can assist patients in times of need. Such a listing may include the following: ❖ ❖ ❖ ❖
Adult day care centers Transportation services Physical therapy and occupational therapy services Support group information:
❖ ❖ ❖ ❖ ❖ ❖
❖ Cancer support groups ❖ Alzheimer support groups ❖ Alcoholics Anonymous ❖ Smoking cessation Public Health Department information Department of Health and Human Services Battered Woman’s Shelter information Social Service organizations Mental health centers Interpreting services
Medical assistants can find many resources in the phonebook or on the Web. Getting the patient the resources that are needed will assist in patient compliance and in improving the overall quality of the patient’s life.
PROCEDURE 9-1 Provide Instruction for Health Maintenance and Disease Prevention and Identify Community Resources That Will Assist the Patient Objective: To provide a patient education session by collecting the appropriate learning materials, obtaining the names and numbers of resources that can assist with compliance, and delivering a successful educational session.
Equipment/Supplies: ❖ Learning tools (pamphlets, brochures, models, multimedia projector, computer) ❖ Community resource information
❖ Patient’s chart ❖ Black pen
PROCEDURAL STEPS
RATIONALE
1. Read and clarify the order from the provider.
It is important to understand what the provider would like the patient to get out of the session.
2. Collect the learning tools necessary for session. 3. Collect numbers or e-mail addresses of community resources, if applicable.
Patients that will need assistance such as in-home help or financial assistance with drugs should be given a list of resources for such services.
4. Review the information and ask the provider questions if unclear about certain aspects of the material.
You cannot do an adequate job of teaching if you yourself do not understand the material that is being presented.
PAT I E N T E D U C AT IO N
PROCEDURAL STEPS
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RATIONALE
5. Set up the room so that everyone in the session has a seat and can see each other. Make certain that the room is free from distractions and has plenty of electrical outlets for necessary equipment.
Each individual should be able to see the presenter and each other to assist with communication.
6. Identify the patient using two identifiers and family members or friends who have accompanied the patient.
Family members will more than likely assist the patient with compliance.
7. Identify yourself and state your title. 8. List the purpose of the session. 9. Find out the patient’s preferred learning style and set goals to determine what the patient and family members want to accomplish from the session.
Ascertaining the patient’s preferred learning style will assist you in knowing how to proceed with the presentation. Setting goals will help you know what the patient hopes to achieve from the session.
10. Present the information in a clear manner, checking with the patient and family members along the way to make certain that they have a clear understanding of what is being presented.
Having checkpoints throughout the session helps to ensure that the patient comprehends the material.
11. Summarize the presentation at the end of the session. 12. Have the patient repeat the information. If a demonstration was incorporated into the session, have the patient demonstrate the procedure back to you.
This illustrates patient comprehension.
13. Praise the patient for acknowledgment of the material.
This helps to validate to the patient that the material has been comprehended.
14. Give the patient learning pamphlets, information sheets, prescriptions, and supplies, and provide a list of resources that can assist the patient with any special needs (Figure 9-5).
Giving the patient tools to take home will assist in patient compliance.
FIGURE 9-5 The patient should be given pamphlets, brochures, and information sheets that will help with any questions the patient may have once home.
15. Give the patient your card or a piece of paper with your name and office phone number. Encourage the patient to call you with any questions.
Giving the patient your card lets the patient know that you care and want to be contacted.
16. Dismiss the patient and document the session. continues
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continued
DOCUMENTATION EXAMPLE:
04-15-09 1200
Educational session on diabetes management per Dr. Fisher. Pt.’s wife present for session. Gave pt. several educational brochures and names and numbers of organizations that may be able to assist pt. with obtaining free test strips and supplies. Also gave the pt. the names and numbers of several dieticians in the area and instructed pt. to set up an appointment with dietician in the next week. Pt. repeated back information, and stated that he would set up an appt with the dietician tomorrow. Encouraged pt. to call back with any questions. Sandy Jancowski, CMA (AAMA)
Chapter Summary Education is important for disease management, health maintenance, and disease prevention. The medical assistant must have a thorough understanding of the topic before presenting information and should provide the patient with learning materials and resources to aid in compliance. Establishing the patient’s preferred learning style and tailoring the presentation to the individual needs of each patient will assist in a successful educational outcome to the session. The medical assistant should draw in family members during the educational encounter so that they can assist the patient with both comprehension of the material and compliance. The medical assistant can be instrumental in creating a positive impact in the lives of patients by taking an active role in their health and well-being. Education can help to improve the patient’s health, prevent disease, and assist patients in taking actions that will add years to their lives.
FIELD APPLICATION CHALLENGE While speaking to the patient about a newly prescribed medication, you notice that the patient appears to be slightly agitated. The patient tells you that he has a part-time job with limited benefits and that he doesn’t qualify for any kind of prescription coverage. There is no generic substitute for this drug, and it is important in the patient’s recovery. 1. What should be your first course of action?
2. What are some additional actions that you may take to assist the patient in getting some financial relief? 3. What should you do if the patient refuses assistance and states that he doesn’t want the drug and that everyone would be much better off if he would die?
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Chapter Assessment
Web Activities
1. All of the following are basic theories regarding adult learning except: a. Adults tend to integrate new information with past experiences and prior education. b. Adults tend to prefer self-directed education rather than group involvement. c. Adults prefer the medical assistant to set the pace for their learning, controlling start and stop times. d. A comfortable learning environment contributes to the successfulness of the session.
1. Go to the U.S. Department of Health & Human Services’ Web site (www.hhs.gov). Click on the topic “Aging.” Print out materials that would assist caregivers providing care for a loved one.
2. Barriers to education include: a. time. b. money. c. interest. d. all of the above. 3. Skills related to good verbal communication are: a. echoing. b. reassurance. c. empathy. d. summarization. e. all of the above. 4. Brochures, DVDs, PowerPoints, slides, photos, handouts, models, and the Internet are excellent tools for which of the following learning styles? a. Visual b. Audio c. Tactile d. All of the above 5. Tips for patient compliance include all of the following except: a. Prevent family members from being in the room during the education session. b. Look for indications that the patient understands and agrees with the material being presented. c. Be a good role model. d. Give the patient related supplies.
2. Type the following words into a search engine: “Diabetes News.” Search at least three articles from three different Web sites and write a two-page paper about the latest treatments for diabetes.
CONNECTION Using your StudyWARE CD-ROM: ❖ Complete the Hangman and Concentration activities for this chapter. ❖ Complete the Quiz for this chapter in Test Mode.
THE DVD LINK On your StudyWARE CD-ROM, go to the DVD Challenge for this chapter. View the DVD clip and respond to the following questions: 1. What did Jae Min do to make certain that she had a clear understanding of the physician’s orders? 2. What did Jae Min need to check before giving out information to Mr. Wilson’s wife? 3. Do you feel that Jae Min’s accent contributed to Mr. Wilson’s inability to understand her? If so, is there anything that Jae Min can do to assist her with communicating over the phone?
C H A P T E R
Principles of Infection Control and OSHA Standards Chapter Outline The Infection Process The Chain of Infection Causative Agents Reservoir Portal of Exit Mode of Transmission Portal of Entry Susceptible Host Environmental Requirements for Microorganisms Stages of Infection Invasion and Multiplication Stage Incubation Stage Prodromal Stage Acute Stage Declining Stage Convalescent Stage
The Body’s Mechanisms of Defense The Process of Inflammation The Immune System The Immune Response Types of Immunity Immunizations Types of Vaccines Infection Control Medical Asepsis Universal Blood and Body Fluid Precautions Standard Precautions Transmission-Based Precautions Commonly Transmitted Bloodborne Diseases AIDS Hepatitis
10 Essential Terms acquired immune deficiency syndrome (AIDS) antibody antigen biohazard bloodborne pathogen body substance isolation (BSI) cell-mediated immunity Centers for Disease Control and Prevention (CDC) disinfection engineering controls epidemiology exposure control fomites humoral immunity immunity immunoglobulin immunosuppressed infection control continues
PRINCIPLES OF INFECTION CONTR OL AND OSHA STANDARDS
KEY COMPETENCIES
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CAAHEP
ABHES
Medically Aseptic Handwash
III.C.3.b.1.a
VI.A.1.a.4.c
Performing an Alcohol-Based Hand Rub
III.C.3.b.1.e
VI.A.1.a.4.c
Removal of Contaminated Gloves
III.C.3.b.1.d III.C.3.b.1.e
VI.A.1.A.4.q
infectious waste inflammatory response medical asepsis microorganism normal flora Occupational Safety and Health Administration (OSHA) opportunistic infections other potentially infectious material (OPIM) pathogen personal protective equipment (PPE) regulated waste resident flora resistance sanitization seroconversion sharps Standard Precautions sterilization surgical asepsis transient flora Transmission-Based Precautions Universal Precautions vector work practice controls
OSHA Regulations Bloodborne Pathogen Standard Blood, Body Fluids, and OPIM Exposure Determination Exposure Control Plan The Biohazard Label
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Exposure to Hazardous Chemicals Chemical Hygiene Plan Safeguards in the Educational Environment
Developmental Objectives After completing this chapter, you should be able to: 1. Correctly spell and define the essential terms. 2. List and define steps in the chain of infection. 3. List the five classifications of pathogenic organisms. 4. List and describe the six stages of infection. 5. Describe the inflammatory response. 6. Describe the four different types of immunity. 7. List and describe the different forms of vaccines available. 8. Explain the difference between medical and surgical asepsis. 9. List at least eight infectious diseases, their causative agents, and some signs and symptoms of each. 10. Explain the difference between Universal Precautions, Standard Precautions, and Transmission-Based Precautions. 11. Discuss the means of transmission for HIV as well as the stages of HIV infection and criteria used to diagnose AIDS. 12. List the five different types of hepatitis and how each is transmitted. 13. State the reason for the development of the Bloodborne Pathogen Standard and the areas governed by the standard. 14. List examples of body fluids and OPIM. 15. List the different types of PPE and state when each should be worn. 16. State the engineering and work practice controls necessary to minimize or eliminate employee exposure. 17. Describe the proper protocol for regulated waste disposal. 18. Be able to locate and use the MSDS manual. 19. List the safeguards to be followed in the classroom and educational laboratory.
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Introduction One of the most important objectives in the ambulatory care setting is to prevent the spread of infectious disease. The medical assistant must be vigilant in the practice of infection control to promote the health and safety of patients, as well as members of the health care team. This chapter will discuss the infection process as well as infection control standards and guidelines developed by the Centers for Disease Control and Prevention (CDC) and the Occupational Safety and Health Administration (OSHA). Strict adherence to these guidelines will ensure that the medical office is a safe place for patients, their family members, and all those that work in the health care setting.
to diseases such as smallpox, tuberculosis, pneumonia, and influenza. The science of epidemiology (the study of infectious diseases) as well as the development of powerful pharmacological agents has virtually eliminated many of these deadly diseases, while others have become easily treatable. Infinite numbers of microorganisms are present everywhere in our environment—on doorknobs, on silverware, in bathrooms, and even in the water supply. Some microorganisms are helpful, providing protection and promoting the survival of plants, animals, and humans. These micoorganisms are called normal flora. Microorganisms that cause disease are known as pathogens, and are able to enter our bodies and multiply, causing us to become sick.
THE CHAIN OF INFECTION
THE INFECTION PROCESS In earlier centuries, infectious diseases were the most common causes of death. A multitude of lives were lost
For an infectious disease to be transmitted from one individual to another, a definite series of steps known as the chain of infection must take place (Figure 10-1).
FIGURE 10-1 The chain of infection and various means of interrupting the spread of infection.
Intact immune system
Infectious Agent
Cleansing
1.
Exercise
Disinfection Immunization Proper nutrition
Sterilization
Susceptible Host
2.
6.
Reservoir or Source
Skin integrity
Proper hygiene
Sterile technique
Clean dressing
Proper disposal of needles or sharps
Clean equipment Clean linen
Portal of Entry to Host
5.
3.
Wearing gloves, masks, gowns, goggles
Clean dressing over wounds
Medical or surgical asepsis Proper disposal of contaminated objects Handwashing
Portal of Exit from Reservoir or Source
4. Means of Transmission
Covering mouth and nose when coughing or sneezing
PRINCIPLES OF INFECTION CONTR OL AND OSHA STANDARDS
An interruption to any of the links in the chain will bring a halt to the infection process. The medical assistant should learn the links within the chain of infection and take active steps to interrupt those links, thereby preventing the transmission of disease from one individual to another. The links include: Causative agents Reservoir Portal of exit Means of transmission Portal of entry Susceptible host
Causative Agents In order to design an appropriate treatment plan for a patient with an infectious disease, it is first necessary to identify the pathogen that caused the disease. Pathogenic organisms are divided into five different classifications: viruses, bacteria, fungi, parasites, and rickettsiae. Knowing the causative organism of a disease can also assist the medical assistant in determining measures that should be taken in order to prevent its spread.
Viruses Viruses are submicroscopic parasites and are the smallest of all living organisms. They are often referred to as “nonliving” because they lack either deoxyribonucleic acid (DNA) or ribonucleic acid (RNA) and need a living host in order to divide and multiply. However, viruses can “live” outside of a host body for a brief period of time. The time a virus can live outside the body will vary from minutes to days, depending on the type of
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virus and its exact environment. Because viruses need a living cell in order to reproduce, they are classified as intracellular parasites. Viruses function by changing bits of genetic material (like DNA and RNA) within the cell. They possess the unusual quality of being able to change certain characteristics of cells and over time are capable of adapting to their surroundings. This quality makes it difficult to develop drugs to cure a viral infection. Viruses are resistant to many chemical agents such as low-level disinfectants, but are highly susceptible to heat. Examples of diseases caused by viruses include colds, influenza, HIV (the virus that causes AIDS), and chicken pox.
Bacteria Bacteria are single-celled microbes that lack a nucleus yet are capable of carrying out everyday life functions. They are the most prevalent of all organisms and live everywhere—including in soil, water, plants, animals, and humans. Millions of bacteria live on the surface of the human skin, in mucous membranes of the nose and mouth, and in the gastrointestinal tract. Bacteria can be nonpathogenic or pathogenic in nature. Normal flora, described earlier in the chapter, is an example of nonpathogenic bacteria. Examples of diseases caused by pathogenic bacteria include strep throat, bacterial pneumonia, and bacterial meningitis.
Fungi Fungi, which include yeast and molds, develop as single cells (unicellular) or multiple cells (multicellular). Some fungi are nonpathogenic, such as mushrooms and molds, while others are pathogenic, causing
F IELD SM A RTS Normal flora in the body helps to keep the number of yeast in the body in check. This is because the normal flora and yeast compete for the same nourishment. When patients take antibiotics over a prolonged period of time or take large doses of antibiotics, the antibiotics remove bad bacteria; however, they may also remove good bacteria. Without good bacteria, there is room for yeast to multiply, and this may eventually cause a yeast infection. This phenomenon is most prevalent in patients taking antibiotics for urinary tract infections. The types of yeast infec-
tions most commonly manifested in patients during or following antibiotic therapy include thrush (a yeast infection of the oral cavity) and vaginal yeast infections. Another condition, known as pseudomembranous colitis, can also occur during or following antibiotic therapy. This condition causes the patient to have severe stomach cramping and uncontrollable diarrhea. You should be familiar with this information so that you can properly educate patients on signs to look for during or following antibiotic therapy.
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conditions such as ringworm, athlete’s foot, vaginal yeast infections, and histoplasmosis (a lung infection transmitted through the droppings of certain birds and bats). Yeast infections are most prevalent in patients with compromised immune systems, patients who are pregnant, and in diabetic patients. Agents that destroy yeast are referred to as antifungal agents.
Parasites Parasites are organisms that must live in or on another organism to receive their nutrients. Parasites can be unicellular or multicellular, and are classified as: ❖ Protozoa: Single-celled pathogens that cause malaria, amoebic dysentery, and vaginal trichomonas infections ❖ Metazoa: Multicelled pathogens that cause hookworms, pinworms, tapeworms, and trichinosis ❖ Ectoparasites: Multicelled pathogens that live on the surface of a host, such as lice and scabies
Rickettsiae Rickettsiae, a type of bacteria, are known as obligate parasites because they require a living cell to grow. They are the causative agent of many diseases, such as Rocky Mountain spotted fever, typhus, and Lyme disease, and are generally transmitted by arthropods (lice, fleas, ticks, and mites). Rickettsiae are highly susceptible to antibiotics.
Reservoir Almost anything can serve as a reservoir in the chain of infection. Humans, animals, vectors (carriers such as insects or rodents), water, food, supplies, and equipment can all be reservoirs in the spread of infectious diseases. In order to break the chain in the reservoir link, the medical assistant should adhere to strict infection control practices, including: ❖ Disinfect work areas, equipment, and supplies that are potentially contaminated by the host. ❖ Wear gloves and other personal protective equipment (PPE) while working with body fluids. ❖ Regularly perform medical aseptic handwashes.
Portal of Exit In order for a pathogen to be spread from one person to the next, it must have a portal of exit, meaning it must have a way to leave an infected individual. Pathogens can leave the body through fluids or drainage in the respiratory tract, gastrointestinal tract, urinary tract, skin, reproductive tract, and mucous membranes. Patients should be advised to cover their mouth while coughing
or sneezing and to keep open wounds properly bandaged. In pregnant women, pathogens can also travel across the placenta and into the baby’s bloodstream.
Mode of Transmission The pathogen must have a method of moving from one individual to another—a mode of transmission. Sometimes, this method will depend on the type of microorganism. There are numerous modes of transmission, including: ❖ Direct transmission/contact: This occurs when an infected person transmits pathogens to another individual through physical contact. This contact can include kissing, sexual contact, or coming into contact with drainage or blood from an open wound on an infected individual. ❖ Indirect transmission/contact: This occurs through ingestion of contaminated foods or drinks, vectors, and fomites, which are contaminated nonliving objects such as water glasses, computer keyboards, telephones, doorknobs, dressings, catheter tubing, needles, and IV tubing. ❖ Droplet transmission: This occurs when an infected person sneezes or coughs. Tiny droplets carrying pathogens can enter an uninfected person through an open portal of entry.
Portal of Entry Once a pathogen leaves the infected individual, it must find a portal of entry in a new host. Often times, the portals of exit and entry are the same. Pathogens may be inhaled through the respiratory tract, ingested through the gastrointestinal tract, absorbed through an opening in the skin such as a tear or wound, or transmitted through sexual contact. The medical assistant should practice careful aseptic technique at all times to prevent pathogens from finding a portal of entry.
Susceptible Host Numerous factors determine whether a person is susceptible to a pathogen once it enters the body. General physical health, underlying disease states, psychological health, and age are all factors that can affect the chain of infection. Patients who are immunosuppressed (meaning that their immune system has been suppressed or weakened) or who have undergone a trauma or surgical procedure are especially at risk. Susceptible patients should be identified and educated on procedures that should be followed in order to prevent exposure. Proper nutrition, exercise, and adhering to the recommended immunization schedule can lessen the body’s susceptibility to pathogens.
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ENVIRONMENTAL REQUIREMENTS FOR MICROORGANISMS Another factor that is important in the spread of microorganisms is the environment. Certain conditions must exist for microorganisms to survive, including the following: ❖ Proper nutrition: Microorganisms must have certain nutrients to grow. Organic materials within the body provide many types of microorganisms with the nutrition needed. ❖ Oxygen: Some microorganisms grow best without oxygen and are referred to as anaerobes. Microorganisms that are dependent on oxygen are referred to as aerobes. Some can grow in either environment and are referred to as facultative aerobes. ❖ Temperature: Optimal temperatures will vary from one microorganism to the next, but most microorganisms thrive at normal body temperatures (98.6°F or 37°C). However, ranges can fluctuate between 77°F and 104°F (25°C and 40°C). ❖ Proper pH: Most microorganism grow best in neutral pH environments (approximately 7.0 on the pH scale), but this will vary depending on the microorganism. ❖ Darkness: Most microorganisms grow best in darkness. ❖ Moisture: Moisture provides a good environment for microorganisms to grow and multiply, as it facilitates cell metabolism. The medical assistant should do everything possible to impede or prevent environmental conditions that are conducive to the growth of pathogenic organisms. For example, the medical assistant should pay close attention to handling and storage instructions for pharmaceuticals and lab specimens. If lab specimens are handled or stored incorrectly, inaccurate readings during testing may occur. In wound care, always keep the outer layer of the dressing dry to prevent microorganisms from getting in the wound.
STAGES OF INFECTION Several stages occur during the infectious disease process. Each stage has its own distinct characteristics (Figure 10-2). Determining which stage of infection the patient is in will assist the provider in developing and monitoring a treatment plan.
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Invasion and Multiplication
Incubation Convalescent
Prodromal
Declining
Acute
FIGURE 10-2 The stages of infection
Invasion and Multiplication Stage The invasion and multiplication stage is the first stage of the infection process. During this stage, the pathogenic microorganism enters the body and begins to multiply. There are no identifiable signs or symptoms during this stage.
Incubation Stage The period of time between exposure to the pathogen and the appearance of the first signs and symptoms of the disease is known as the incubation stage. Some diseases have a short incubation period while in others this stage can last for years.
Prodromal Stage The prodromal stage is the interval of time between the appearance of first signs and symptoms and the appearance of definitive symptoms such as fever and rash. During this stage, the patient may present with a general complaint of malaise.
Acute Stage The infection process reaches its peak during the acute stage. During this stage, symptoms are well-developed, which helps to differentiate one disease from another.
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Declining Stage During the declining stage, symptoms begin to subside. The infection is still present; however, the patient begins to return to the previous state of health.
Convalescent Stage The convalescent stage is the point at which the patient recovers from the infectious disease and returns to the original state of health. Table 10-1 provides information on some of the more common infectious diseases, including the causative agents, means of transmission, and recommended patient care.
THE BODY’S MECHANISMS OF DEFENSE The body has both internal and external mechanisms of defense to combat the invasion of pathogens. Sometimes these defense mechanisms are able to ward off an infection. At other times, the pathogenic microorganisms multiply, gain strength, and overcome the body’s defenses. Natural barriers that assist in preventing infection include: ❖ Intact skin: Keeps microorganisms from entering deeper tissue ❖ Eyelids and eyebrows: Help to keep debris and microorganisms away from the eye region ❖ Tears: Wash debris out of the eye ❖ Mucous membranes: Mucus within the respiratory tract, genital region, and GI tract help to trap microorganisms, and white blood cells within the mucus assist in destroying pathogenic microorganisms ❖ Cilia: Small hairs found in the respiratory tract that trap microorganisms and continually sweep debris toward the outside of the body ❖ Coughing and sneezing reflexes: Help to rid the body of microorganisms ❖ Acids in the stomach and vagina: Provide a hostile environment that hinders the growth of microorganisms In addition to these barriers, the body’s two primary defense mechanisms are the process of inflammation and the immune system.
The Process of Inflammation The changes that occur within body tissues as a response to an injury or a pathogen invasion are
known as inflammation. The inflammatory response is the body’s attempt to protect itself from microorganisms that enter the body and to heal and replace injured tissue. The terms inflammation and infection are not synonymous. A person can have inflammation without infection; however, a person cannot have infection without inflammation. Signs and symptoms of inflammation may be classified as local or systemic. Table 10-2 differentiates local signs of inflammation from systemic signs of inflammation. Sometimes the process of inflammation is not adequate enough to stop the infection. This is indicated by the formation of pus, the swelling of the lymph nodes, or a condition known as septicemia (a condition in which pathogens enter the bloodstream and cause the patient to become very ill). If the inflammatory process is insufficient, antibiotic therapy is usually necessary.
The Immune System The immune system is a complex system that guards the body against pathogens and abnormal cell growth (which stimulates conditions such as cancer). The immune system works to recognize, suppress, fight, and remove pathogens. The immune system promotes immunity (protection from disease) and provides resistance after exposure to a pathogen. The main components of the immune system are macrophages (special cells that engulf or swallow up pathogens), special lymphocytes known as T-cells and B-cells, and protein particles known as antibodies.
The Immune Response When a pathogen enters the body, it is recognized as a foreign invader and the immune system begins to respond. Two immune responses may occur, and these are known as cell-mediated immunity and humoral immunity. During cell-mediated immunity, T-cells, which are produced by the thymus gland and are stored in the lymph tissue, become activated. These specialized lymphocytes are involved in attacks against cancer cells and infections caused by fungi and viruses. They are also the cells responsible for delayed hypersensitivity reactions associated with organ transplants. This type of immune response is referred to as cell-mediated because the T-cells are directly involved in the attack. During humoral immunity, B-cells, which originate in the bone marrow and are stored in lymph tissue, turn into plasma lymphocytes and produce antibodies (substances that neutralize antigens) rather than destroying the antigen (the invading organism) directly, like the T-cell does. Antibodies are specially
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TABLE 10-1 Common Infectious Diseases
DISEASE
CAUSATIVE AGENT
AIDS
MEANS OF TRANSMISSION
PATIENT CARE
HIV (virus)
Unprotected sex, needlesticks from a contaminated needle, and mother to fetus
Antiviral drugs Supportive: management of symptoms
Anthrax
Bacillus anthracis (bacteria)
Handling contaminated wool or hides, undercooked meat of infected animals, inhalation of contaminated soil particles, bio weapons
Penicillin Tetracycline
Botulism
Clostridium botulinum (bacteria)
Ingesting contaminated water or undercooked, contaminated food
Supportive: antitoxin may be given
Chlamydia
Chlamydia trachomatis (bacteria)
Primarily sexual and mother to infant contact
Antibiotics
Chicken pox
Varicella zoster (virus)
Airborne
Supportive: antiviral drugs
E. coli infection
Escherichia coli (bacteria)
Foodborne, person-to-person through poor hygiene/handwashing. Normally found in the lower intestinal tract of animals and humans, but can do a great deal of damage outside of the tract.
Antibiotics Supportive: treat dehydration
Gonorrhea
Neisseria gonorrhea (bacteria)
Unprotected sex, direct contact with exudates of mucous membranes
Antibiotics
Influenza
Influenza viruses A, B, C
Inhalation of droplets and transmission through contact with fomites
Supportive: treatment of symptoms
Legionnaires’ disease
Legionella pneumophilia (bacteria)
Airborne from soil or water source
Antibiotics
Meningococcal (spinal) meningitis
Neisseria meningitidis (bacteria)
Airborne inhalation of respiratory droplets, direct contact with patient’s respiratory secretions
Antibiotics
Salmonellosis
Salmonella (bacteria)
Foodborne, infected animals, turtles, iguanas, some reptiles
Supportive: treatment of symptoms Antibiotics usually not necessary
Shigellosis
Shigella (bacteria)
Person-to-person, contact with infected feces, foodborne, waterborne
Antibiotics Supportive: treat dehydration
Syphilis
Treponema pallidum (bacteria)
Sexual contact, mother to fetus, needlestick, blood transfusion
Penicillin Erythromycin Doxycycline
Tetanus
Clostridium tetani (bacteria)
Puncture wounds or cuts
Supportive: treatment of symptoms
Tuberculosis
Mycobacterium tuberculosis (bacteria)
Droplet inhalation
Antibiotics
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TABLE 10-2 Local and Systemic Signs of Inflammation Local signs
Redness and heat: localized dilation of blood vessels increases blood flow to the area distributing cells that are active in the immune response Pain and swelling: movement of plasma from dilated blood vessels into the tissue, causing pressure on nerves and nerve endings
Systemic signs
Leukocytosis or an increase in the white blood cell count: WBCs help to fight the infection Increased pulse rate: a result of increased circulation Swollen lymph nodes: due to an increase in white cell production Fever: pyrogens released from white blood cells elevate the temperature in the body as an attempt to destroy the microorganisms
designed by the B-cells so that they can lock directly into the antigen, similar to interlocking jigsaw puzzle pieces (Figure 10-3). The antibody is able to release chemicals that flag the antigen for destruction.
Types of Immunity Following exposure to an infectious disease, cells within the immune system store information about the specific antigen into their memory, so the next time the same antigen enters the body, the immune system is able to respond and eradicate the antigen before it causes disease. Immunity, the body’s ability to defend itself against pathogens and toxins, can occur in a variety of different ways: ❖ Natural immunity: Occurs naturally as a result of being exposed to the pathogen. It can be further broken down into: ❖ Natural passive immunity: Antibodies can be passed from mother to fetus or by genetic
FIGURE 10-3 Antigens and antibodies attach to each other in a “jigsaw puzzle” fashion.
Antigen
Antibody
inheritance. Certain races are immune to specific diseases. ❖ Natural active immunity: Immunity is developed as a result of direct exposure to the antigen (such as when infection occurs). ❖ Artificial immunity: Occurs as a result of being injected with either the antigen or antibodies and can be further broken down into: ❖ Artificial passive immunity: Occurs when the patient is given direct antibodies (immunoglobulins) to fight off infection. ❖ Artificial active immunity: Occurs when the patient is given small amounts of the antigen (through immunization) to stimulate an antibody reaction so that by the time the body is exposed to the antigen it already has an arsenal of antibodies ready to attack.
Immunizations Immunizations provide immunity against specific infectious diseases. They also help to protect the general population, especially children and the elderly who are most vulnerable to infection. The U.S. Department of Health and Human Services (HHS) strongly recommends that preschoolers under age two be fully vaccinated (see Chapter 19 for the recommended schedule).
Types of Vaccines A vaccine is an agent capable of producing immunity to an infectious disease. There are several categories of vaccines: 1. Live attenuated: These vaccines are a weakened form of a pathogen, altered by the manufacturer using a specific chemical or mechanical process. This type of vaccine stimulates the immune system to produce antibodies against the pathogen with-
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out causing the patient to contract the disease itself (although in some cases, the patient may experience mild symptoms). Some examples of live attenuated vaccines are the new tuberculosis immunization (BCG); measles, mumps, rubella (MMR); and the smallpox vaccine. 2. Toxin vaccines or antitoxins: These vaccines are toxins produced by pathogens, which have been extracted from the gamma globulin portion of the blood from humans and animals who have been vaccinated against a specific disease. By injecting the toxins produced by some pathogens, the immune system is stimulated to produce antibodies against the specific pathogen. Some examples of toxin vaccines are tetanus antitoxin and diphtheria antitoxin. 3. Killed vaccine: These vaccines are inactivated pathogens (pathogens that have been killed by either physical or chemical means to make them harmless). This type of vaccine will stimulate antibody production by the immune system, although a series of vaccines may be required to produce longterm immunity. Some examples of killed vaccines include whooping cough (pertussis) and rabies. FIGURE 10-4 Different methods of practicing medical asepsis in the medical office
INFECTION CONTROL Medical asepsis and surgical asepsis are two types of infection control that should be regularly practiced in the medical office. Specific procedures and practices will dictate which form of asepsis should be performed by the medical assistant. Medical asepsis applies to the destruction of microorganisms after leaving the body, while surgical asepsis is the destruction of microorganisms before entering the body. See Chapter 24 for a complete description of surgical asepsis.
Medical Asepsis The purpose of medical asepsis is to decrease the risk of spreading infection by blocking or destroying pathogens after they leave the body. Techniques used to institute medical asepsis include performing handwashing on a regular basis; practicing Standard, Universal, and Transmission-Based Precautions (discussed later in this chapter); cleaning and disinfecting countertops, flooring, and exam tables; and using PPE as barriers placed between blood and body fluids and the people who come in contact with them. Figure 10-4 illustrates some of the processes that can be used to institute medical asepsis. Patients should also be taught to practice medical asepsis through frequent handwashing, covering
mouths with a tissue when sneezing and coughing, keeping counter and table surfaces clean and disinfected, and not sharing items such as eating utensils, toothbrushes, and combs.
Handwashing and Gloving Two types of microorganisms commonly found on the hands include resident flora (normal flora) and transient flora (that which is picked up throughout the day). Resident flora is normally found in the epidermis and dermis layers of the skin and is harmless.
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FI E L D S M A R T S All blood and body fluids should be considered potentially infectious, regardless of the source. Never become careless when handling specimens, even if you are familiar with the patient’s history. During the early stages of disease, many people are unaware they are infected, as signs and symptoms may not yet be present.
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Transient flora is found in the superficial layers of the epidermis and is picked up through direct contact— such as touching counter surfaces, people, keyboards, doorknobs, and so on. Transient flora, unlike resident flora, may be harmful; therefore, frequent handwashing is essential. Handwashing is the first line of defense in reducing the spread of infection and should be performed by the medical assistant frequently throughout the workday. Since frequent handwashing may lead to irritation, drying, and dermatitis, the Centers for Disease Control and Prevention (CDC) has developed new guidelines for hand hygiene, which include both an antiseptic handwashing and an alcohol-based hand rub (see Table 10-3). Antiseptic handwashing incorporates the use of an antimicrobial soap, instead of a detergent soap, for deeper cleansing. Many antimicrobial soaps also leave an antibacterial film on the hands for longer-lasting protection. Alcohol-based hand rubs are products that contain 60% to 90% isopropanol or ethanol alcohol. Alcoholbased hand rubs are available in several forms, includ-
ing gels, lotions, and foams. This form of cleansing has been shown to be more effective than soap for removing transient flora from the hands (Figure 10-5). Additionally, alcohol-based hand rubs offer these benefits: ❖ They are easy to use, since they do not require rinsing. ❖ They are quicker than traditional handwashing methods. ❖ They often contain moisturizers, which help to prevent the skin from drying. The medical assistant should wear gloves when there is a risk of hand contact with any blood or body fluid. The CDC recommends that the health care worker wear clean disposable gloves whenever there is potential contact with: ❖ Blood ❖ Other potentially infectious material (OPIM) or body fluids that have potential to transmit disease, including any body fluid that is visibly contaminated with blood; cerebrospinal, amniotic, pericardial, pleural, and peritoneal fluids;
TABLE 10-3 CDC Recommendations for Hand Hygiene When to wash hands with detergent or antimicrobial soap
• If hands become soiled with dirt or body fluids • After using the restroom • Before eating or drinking
When to apply an alcohol-based hand rub
• Before applying gloves and after removing them • Before and after each patient contact • If hands are not visibly soiled, after contact with body fluids, nonintact skin, soiled dressings • During patient care, after moving from a contaminated site to a clean site • After using any medical equipment, computer keyboard, telephone, etc., during the performance of health-care-related job duties
General recommendations
• Keep nails short, less than a 1⁄4 inch long. No acrylic or adorned nails. • Do not add more soap to a dispenser that is low or empty. This could contaminate the soap. Either discard the dispenser or clean the dispenser and then refill it. • Use disposable paper towels to dry hands. • Apply lotions and creams after frequent handwashing to keep hands from drying out. • Wash hands and change gloves if moving from a contaminated site to a clean site. • Wear a clean pair of gloves for each patient.
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FIGURE 10-5 A medical assistant is applying an alcohol-based
Sensitivity to latex products is becoming more prevalent among health care workers and patients. Mild to severe allergic reactions can occur, which may cause anything from a skin rash or hives to anaphylaxis. Because some medical and surgical products are made from latex (including some of the PPE worn by health care providers), it is important to determine an individual’s sensitivity prior to performing a procedure. If a health care worker is sensitive to latex, vinyl gloves should be provided. As an OSHA inspector, I will be checking to make sure that the employer is providing alternatives to latex products for all sensitive employees.
hand rub.
any unidentifiable body fluid; saliva during dental procedures; semen and vaginal secretions; any unfixed human tissue; any tissue or any fluids known to be infected with HIV ❖ Nonintact skin ❖ Mucous membranes Sterile gloves should be worn when performing a sterile procedure, such as assisting with minor surgery. If a facility is following Standard Precautions (see next page), all body fluids (except sweat) are treated as potentially infected. Refer to Procedures 10-1, 10-2, and 10-3 for step-by-step instructions for handwashing, using alcohol-based hand rubs, and applying and removing gloves.
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CR ITI C A L TH I N K I N G C H AL LEN G E There is no sink with running water near your desk. Patients and other coworkers are continually stopping by your desk to drop off and pick up items. You use the keyboard and pick up the phone several times per day. 1. What can you do to institute good hand hygiene without constantly leaving your desk?
Sanitization Sanitization is the process by which contaminated instruments and fomites are cleansed and scrubbed to remove potentially infectious materials such as blood, body fluids, and tissue debris. This process should be performed as soon as possible after contamination has occurred. Instruments may be placed in a soaking solution while waiting to be sanitized (Figure 10-6).
Disinfection
FIGURE 10-6 Instruments are
Disinfection is the soaked immediately after use. use of chemical agents to destroy pathogenic organisms. The majority of disinfectants are not able to kill large numbers of spores, which are the most resistant of all microorganisms. Disinfection is performed on inanimate (nonliving) objects such as counter surfaces, flooring, and some instruments. Disinfectants are generally not used on the skin because the chemicals used in disinfectants can be irritating to the skin and mucous membranes. Chemical disinfectants are used for large instruments, scopes,
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and items that could be damaged by heat. Sanitization should be performed on an item prior to disinfection.
ble infection control program, the following standards should be instituted:
Sterilization
❖ All blood and body fluids should be considered contaminated. ❖ Wash hands before and after each patient, and when hands become contaminated with blood or body fluids. ❖ Wear gloves when performing any task, such as venipuncture, finger sticks, heel sticks, and laboratory tests in which there could be contact with a patient’s blood, body fluids, mucous membranes, broken skin, wounds, or body tissue. ❖ Change gloves after each patient. Never wear the same pair of gloves for more than one patient. ❖ Wash hands before donning gloves and after removing gloves. ❖ When there is a risk of contamination due to splashing or droplets of blood or body fluids, wear protective barriers (such as a gown, mask, goggles/ face shield) in addition to gloves (Figure 10-7). ❖ When handling sharps (Figure 10-8) (which include needles, sharp instruments, scalpels, glass slides, glass tubes, and pipettes), exercise extreme
Sterilization is the complete destruction of all microorganisms and is the process that should be used on any instrument that will penetrate the skin. Autoclaving is a process in which heat, steam, and pressure are used to destroy all forms of microorganisms, including large numbers of spores. Refer to Chapter 22 for procedures on sanitization, disinfection, and sterilization.
UNIVERSAL BLOOD AND BODY FLUID PRECAUTIONS In 1987, the CDC established standards and guidelines known as Universal Blood and Body Fluid Precautions, or Universal Precautions, to help control the transmission of HIV and the hepatitis B virus (HBV) in the health care setting. While developed to specifically combat HIV and HBV, strict adherence to the guidelines has shown a great reduction in the risk of spreading all infectious disease. Universal Precautions is an approach to infection control that treats all human blood and OPIM as if they were known to be infected with HIV, HBV, and other bloodborne pathogens. Universal Precautions are practiced more often in ambulatory care settings such as clinics and medical offices.
Standard Precautions In 1996, the CDC developed a new set of guidelines known as Standard Precautions. Standard Precautions include the previous Universal Precautions, as well as an additional practice called body substance isolation (BSI). BSI takes Universal Precautions to the next level by requiring barriers for all body substances, including those secretions or excretions that are not considered OPIM (except for sweat), such as tears, saliva, urine, mucus secretions, and wound drainage. Standard Precautions were developed for inpatient facilities such as hospitals and nursing homes, although many ambulatory care centers have adopted them. Recently, the CDC added more guidelines to Standard Precautions including: respiratory hygiene/cough etiquette, safe injection practices, and the use of masks for insertion of catheters or injection of material into spinal or epidural spaces via lumbar puncture procedures. To reduce the likelihood of transmitting infectious disease, the CDC now recommends that every patient be considered potentially infectious for all bloodborne pathogens. Thus, as part of an effective and responsi-
FIGURE 10-7 A medical assistant wearing full personal protective equipment (PPE)
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❖ Immediately report any exposure to contaminated materials (such as splashes or needlesticks) and be sure to follow the established workplace protocol after such occurrences. ❖ When performing CPR, use a mask to decrease exposure to saliva. ❖ Any break in the skin of a health care worker must be covered and protected to prevent exposure to contaminated material. Figure 10-10 displays a list of Standard Precaution symbols and an explanation of each one.
Transmission-Based Precautions
FIGURE 10-8 The medical assistant should place the entire safety needle and syringe unit in an approved puncture-proof sharps container following use.
caution. Anything sharp, especially items contaminated after a procedure, must be placed in an approved puncture-proof container that displays the biohazard symbol. These containers should be placed in various locations throughout the work area and should be easily accessible. ❖ Clean all spills (blood and body fluids) immediately with an approved disinfectant or a simple 10% sodium hypochlorite solution, which is household bleach (Figure 10-9).
FIGURE 10-9 The medical assistant cleans the workstation counter with a 10% bleach solution following the performance of a lab test.
In 1996, the CDC developed Transmission-Based Precautions as a counterpart to the Standard Precautions. Transmission-Based Precautions were designed to decrease the risk of transferring pathogens by direct or indirect contact, or through droplet transmission, and must always be used in conjunction with Standard Precautions when dealing with patients with known highly infectious diseases. Examples of TransmissionBased Precautions include: ❖ Indirect contact/airborne precautions: Include the use of respirators and surgical masks as well as placing the patient in a private room with filtered air ❖ Direct contact precautions: Include the use of all PPE (gloves, gowns, shields) and the cleaning and disinfecting of all equipment if used by or for more than one patient ❖ Droplet precautions: Include wearing a mask and eye protection or a complete face shield when there is the potential of droplet contamination
COMMONLY TRANSMITTED BLOODBORNE DISEASES Acquired immune deficiency syndrome (AIDS) is a disease that is on the forefront of the minds of most health care workers considering the risks of working in the health care field. While AIDS is a threat to health care workers, both HBV and hepatitis C virus (HCV) actually pose more of a threat.
AIDS AIDS is caused by a bloodborne virus known as the human immunodeficiency virus (HIV) and is the last stage of the virus. The virus attacks the white blood cells known as CD4 cells or T-cells, which protect the body against many types of infections. As the disease progresses, fewer T-cells are available to fight off
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FIGURE 10-10 Standard Precaution symbols (Courtesy of Brevis Corp.)
infections and cancers that a normal, healthy immune system would be able to do. These illnesses are referred to as AIDS-defining illnesses because they are typical illnesses that are seen in patients with progressed HIV or AIDS. Many of the infections listed as AIDS-
defining illnesses are also referred to as opportunistic infections because they are infections that normally do not occur unless the infected individual has an impaired or weakened immune system. Examples of these illnesses can be found in Table 10-4.
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TABLE 10-4 Diagnostic Criteria for HIV Infection and AIDS and Opportunistic Infections Indicating AIDS DIAGNOSTIC CRITERIA FOR HIV INFECTION
DIAGNOSTIC CRITERIA FOR AIDS FROM THE CDC
EXAMPLES OF OPPORTUNISTIC INFECTIONS AND CAUSATIVE AGENTS
ELISA test: primarily used to screen for HIV antibodies; can show false positive results. If the ELISA test is positive, repeat the test two more times.
The CDC requires a positive confirmatory test for HIV infection and at least one of the following:
Candida infections (candidiasis) of the trachea, bronchi, lungs, or esophagus
Western blot test: used to confirm a positive ELISA test Coulter HN-p24 antigen assay: detects the presence of the HIV antigen; used when patients show both negative ELISA and Western blot tests, but are suspected of being HIV positive
CD4 count: measures the number of helper T lymphocytes; results of <200/cu mm or <14% of the total lymphocytes Presence of opportunistic infections AIDS-related cancers: • Kaposi’s sarcoma • Burkitt’s lymphoma • Primary brain lymphoma • Immunoblastic lymphoma • Invasive cervical cancer
Cytomegalovirus: infections affecting areas of the body other than the liver, spleen, or lymph nodes Cytomegalovirus retinitis: causing loss of vision Herpes simplex: chronic ulcers of the mouth of longer than 1 month’s duration, bronchitis, pneumonitis, or esophagitis Mycobacterium avium or Mycobacterium kansasii: extrapulmonary infections or disseminated Mycobacterium tuberculosis: pulmonary or extrapulmonary infections Pneumocystis carinii pneumonia
Diagnostic Criteria for Diagnosing a Patient with AIDS Table 10-4 lists the criteria for diagnosing HIV infections and AIDS, as well as the opportunistic infections developed by patients with AIDS.
Stage 1: Primary HIV Infection This stage begins when an individual becomes infected with the virus. During this stage, the individual may develop flu-like symptoms that occur one to four weeks following exposure. There are large amounts of HIV antigens present during this stage and the body starts to manufacture
Stages of HIV There are usually four stages associated with HIV, although some infected individuals may not experience every stage.
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F IEL D S M A R T S Keep in mind that not everyone who has an opportunistic infection or an infection that is listed as an AIDS-defining illness has AIDS. Individuals are simply more prone to these types of illnesses when they have a weakened immune system, such as in patients with AIDS.
The results of all testing, especially testing for HIV, must be kept completely confidential. For this reason, many facilities assign patients who are undergoing HIV testing a tracking number that identifies that patient and the patient’s specimen. The number is used on all correspondence regarding the HIV testing, including the results. A positive HIV test result can adversely affect a patient’s lifestyle, including employment. Always follow HIPAA guidelines when handling test orders and results.
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antibodies against the virus. This is the stage in which seroconversion takes place, which is the point that detectable antibodies are present in the serum, causing a positive antibody test. Seroconversion can occur anywhere from two weeks to six months following exposure. HIV antibody testing may present a false negative during initial testing. Stage 2: Clinically Asymptomatic Stage During the second stage, which may last for several years, the infected individual usually has no detectable symptoms, other than some enlarged lymph nodes. The level of HIV present in the peripheral blood stream drops during this stage, but HIV antibody testing will still reveal a positive HIV antibody test. Although the virus tapers off in the peripheral blood, it is usually very active within the lymph nodes at this stage. Stage 3: Clinically Symptomatic Stage In the third stage, the individual starts to show signs of AIDS. Symptoms start out mild but progress into something more severe. Swollen glands may be present during this stage, along with diarrhea, fatigue, mouth ulcers, nail fungus, thrush, and significant weight loss. Stage 4: Progression of HIV to AIDS In the fourth and final stage of an HIV infection, the individual becomes very sick. AIDS is usually fatal; however, with the latest treatment options, many patients are able to live for many years. Most patients do not succumb to the disease itself, but rather to opportunistic infections and cancers allowed by their weakened immune state. The CDC estimates that over one million Americans are now living with HIV, and 24% to 27% of those people are unaware of their HIV infection.
Both HIV and HBV are transmitted by direct contact with infected blood and body fluids, including: ❖ Accidental puncture with contaminated sharp objects such as needles, scalpels, or broken glass ❖ Sharing of needles by IV drug users ❖ Receiving a transfusion of blood or blood products from an infected person (this risk is now greatly reduced as blood and blood products used for transfusion are now screened for both HIV and HBV) ❖ Sexual contact with infected person (HIV was once only considered a disease affecting the homosexual community, but is now known to be prevalent in heterosexuals and bisexuals as well) ❖ Any break in the skin coming in contact with contaminated blood and body fluids ❖ Infection passed from mother to fetus ❖ Contaminated tools and needles used for body piercing and tattooing ❖ HBV only—indirect transmission (such as touching contaminated dried or caked blood and then touching eyes, mouth, nose, or broken skin)
OSHA REGULATIONS The Occupational Safety and Health Administration (OSHA) was created in 1971 by the federal government to establish standards and regulations for all employers to ensure that employees work in a safe and healthy work environment. Employment in the health care field presents risks not found in other work environments due to exposure to potentially infectious
Hepatitis There are five known viral hepatitis diseases: hepatitis A, B, C, D, and E. All of these viruses inflame the liver and cause destruction of hepatic cells (see Table 10-5). HBV poses the greatest threat to health care workers and is more easily contracted than HIV. However, HBV is almost entirely preventable by strictly observing the rules of infection control and Standard Precautions. Also a vaccine has been developed for HBV and is recommended for all health care workers and people working in other high-risk environments. Figure 10-11 provides facts about HBV, vaccine information, an employee’s right to decline the vaccine, and steps to be followed by an employer if an exposure incident occurs. HCV, although not as prevalent as HBV, is another form of hepatitis that can be transmitted in the health care setting.
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FI E L D S M A R T S Persons with acute hepatitis C may complain of fatigue, abdominal pain, and have jaundice—or they may not have any symptoms at all. Following the acute stage, symptoms may not be present for 20 or 30 years. Cirrhosis develops in about 10% to 20% of patients with chronic hepatitis C, and those patients are at higher risk for liver cancer. Hepatitis C is the major reason for liver transplants in the United States today. There is currently no vaccination for this type of hepatitis.
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TABLE 10-5 Types of Hepatitis Viruses HEPATITIS VIRUS
CAUSATIVE AGENT
MEANS OF TRANSMISSION
A
HAV
B
SYMPTOMS
PROGNOSIS
Contaminated food and water
Flu-like Jaundice Dark yellow urine Light stools
Does not become chronic Does not become a carrier
HBV
Blood or body fluids of infected person
Acute: Incurable Jaundice May become a carrier Nausea and vomiting Joint pain Rashes Chronic: Typically asymptomatic Detected only by blood test Late complications Cirrhosis Portal hypertension Liver cancer
C
HCV
Bloodborne Transfusions Organ transplant
Flu-like Jaundice Abdominal pain May be asymptomatic
75% to 85% develop chronic hepatitis
D
HDV
HBV must be present also
Severe acute disease or chronic progressive disease Flu-like May be jaundiced
Does not commonly become chronic
E
HEV
Contaminated food and water
Fever Jaundice Abdominal pain Loss of appetite
Does not become chronic
It is important to educate patients with HBV and HCV about the means of transmitting the disease to family members and others. Since these viruses are transmitted through blood and body fluids, educate patients on the following precautions: ❖ Do not share toothbrushes, razors, or syringes. ❖ Protect open sores. ❖ Always practice protected sex.
In addition, hepatitis patients should: ❖ Not drink alcohol. ❖ Use caution when taking medications such as acetaminophen (the generic name for Tylenol), which can be toxic to the liver. ❖ Not donate blood. ❖ Avoid raw foods such as oysters, clams, or ground beef. HCV patients should be vaccinated against hepatitis A and B if they are not already immune.
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BLOODBORNE FACTS WHAT IS HBV? Hepatitis B virus (HBV) is a potentially life-threatening bloodborne pathogen. Centers for Disease Control estimates there are approximately 280,000 HBV infections each year in the United States. Approximately 8,700 health care workers each year contract hepatitis B, and about 200 will die as a result. In addition, some who contract HBV will become carriers, passing the disease on to others. Carriers also face a significantly higher risk for other liver ailments which can be fatal, including cirrhosis of the liver and primary liver cancer. HBV infection is transmitted through exposure to blood and other infectious body fluids and tissues. Anyone with occupational exposure to blood is at risk of contracting the infection. Employers must provide engineering controls; workers must use work practices and protective clothing and equipment to prevent exposure to potentially infectious materials. However, the best defense against hepatitis B is vaccination.
WHO NEEDS VACCINATION? The new OSHA standard covering bloodborne pathogens requires employers to offer the three-injection vaccination series free to all employees who are exposed to blood or other potentially infectious materials as part of their job duties. This includes health care workers, emergency responders, morticians, first-aid personnel, law enforcement officers, correctional facilities staff, launderers, as well as others. The vaccination must be offered within 10 days of initial assignment to a job where exposure to blood or other potentially infectious materials can be “reasonably anticipated.” The requirements for vaccinations of those already on the job took effect July 6, 1992.
WHAT DOES VACCINATION INVOLVE? The hepatitis B vaccination is a noninfectious, yeast-based vaccine given in three injections in the arm. It is prepared from recombinant yeast cultures, rather than human blood or plasma. Thus, there is no risk of contamination from other bloodborne pathogens nor is there any chance of developing HBV from the vaccine. The second injection should be given one month after the first, and the third injection six months after the initial dose. More than 90 percent of those vaccinated will develop immunity to the hepatitis B virus. To ensure immunity, it is important
for individuals to receive all three injections. At this point it is unclear how long the immunity lasts, so booster shots may be required at some point in the future. The vaccine causes no harm to those who are already immune or to those who may be HBV carriers. Although employees may opt to have their blood tested for antibodies to determine need for the vaccine, employers may not make such screening a condition of receiving vaccination nor are employers required to provide prescreening. Each employee should receive counseling from a health care professional when vaccination is offered. This discussion will help an employee determine whether inoculation is necessary.
WHAT IF I DECLINE VACCINATION? Workers who decide to decline vaccination must complete a declination form. Employers must keep these forms on file so that they know the vaccination status of everyone who is exposed to blood. At any time after a worker initially declines to receive the vaccine, he or she may opt to take it.
WHAT IF I AM EXPOSED BUT HAVE NOT YET BEEN VACCINATED? If a worker experiences an exposure incident, such as a needlestick or a blood splash in the eye, he or she must receive confidential medical evaluation from a licensed health care professional with appropriate follow-up. To the extent possible by law, the employer is to determine the source individual for HBV as well as human immunodeficiency virus (HIV) infectivity. The worker’s blood will also be screened if he or she agrees. The health care professional is to follow the guidelines of the U.S. Public Health Service in providing treatment. This would include hepatitis B vaccination. The health care professional must give a written opinion on whether or not vaccination is recommended and whether the employee received it. Only this information is reported to the employer. Employee medical records must remain confidential. HIV or HBV status must NOT be reported to the employer. U.S. Department of Labor Occupational Safety and Health Administration Single copies of fact sheets are available from OSHA Publications, Room N3101, 200 Constitution Ave. N.W., Washington, D.C. 20210 and from OSHA regional offices.
FIGURE 10-11 Bloodborne Facts, published by the United States Department of Labor, OSHA, contains information about hepatitis B virus, HBV vaccine, declining the HBV vaccine, and protocol following exposure to blood, body fluids, or OPIM.
PRINCIPLES OF INFECTION CONTR OL AND OSHA STANDARDS
materials. Thus two sets of standards were developed to protect employees in the health care field—The Hazardous Communications Standard, which includes standards that protect against exposure to hazardous chemicals in the laboratory—and The Bloodborne Pathogens Standard.
Bloodborne Pathogen Standard A bloodborne pathogen is defined as a pathogen that can be transmitted by means of blood or OPIM. The Bloodborne Pathogens Standard, published by OSHA in 1991, was established to reduce the risk of developing occupationally related diseases such as AIDS and hepatitis B and C by health care workers. These standards are designed to protect any employee who comes into contact with blood or OPIM while performing regular job duties. These standards include rules for controlling exposure, exposure determination, disposal of biohazardous waste, postexposure follow-up, housekeeping and laundry procedures, labeling of hazardous materials, HBV vaccine, and employee training.
Blood, Body Fluids, and OPIM OSHA and the CDC have listed the following as potentially infectious fluids from which health care workers should protect themselves. These fluids follow right along with the blood and body fluids listed as potentially infectious when following CDC guidelines for gloving: ❖ Blood and blood components ❖ Body fluids such as cerebrospinal fluid, synovial fluid, pleural fluid, peritoneal fluid, and pericardial fluid ❖ Any body fluid visibly contaminated with blood ❖ Saliva during dental procedures ❖ Semen and vaginal secretions ❖ Unfixed human tissues, such as biopsy specimens ❖ Specimens of unknown origin ❖ Any specimen including fluid, cells, or tissue cultures that are contaminated with HIV, HBV, or HCV Remember that if a facility is following Standard Precautions, all body fluids should be considered potentially infected.
Exposure Determination Exposure determination requires that employers maintain a list of job classifications in which: ❖ All employees in that job are likely to be exposed to blood and OPIM. Examples of these classifica-
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tions are medical assistants, nurses, physicians, and lab technicians. (It is not necessary to list hazardous duties for this classification.) ❖ Some employees may be exposed to blood and OPIM, along with a list of the hazardous duties for the classification. Examples of personnel in this classification include housekeeping and laundry staff.
Exposure Control Plan OSHA requires all employers with employees who have occupational exposure to blood and OPIM to set up a written exposure control plan. This plan should be designed to reduce or eliminate employee exposure. The plan should include: ❖ Compliance rules for exposure prevention ❖ Hepatitis B vaccination, postexposure evaluation, and follow-up procedures ❖ A listing of all hazards to employees (employees must be informed of the hazards; a written plan must be available to all employees and should be updated and modified each year) ❖ Guidelines for the employee to follow through the reporting process ❖ Recordkeeping procedures A copy of the exposure control plan must be easily accessible to all employees and must be reviewed and updated at least annually. The plan must also be updated if new tasks and procedures are adopted where exposure is probable.
Compliance Rules for Exposure Prevention OSHA has established methods of compliance to prevent exposure to blood and OPIM, including practicing Standard Precautions, wearing appropriate personal protective equipment (PPE), implementing engineering controls and work practice controls, properly disposing of regulated waste, and maintaining a clean work space. When following Standard Precautions, health care workers should treat all blood, body fluids, and bodily materials as potentially infectious. Employers must provide adequate and easily accessible handwashing stations and ensure that all employees wash their hands and any contaminated skin with soap and water following exposure to blood and OPIM. If mucous membranes have been exposed, they must be flushed immediately with water (Figure 10-12). PPE should be worn to provide a protective barrier between the employee and blood and OPIM. Figure 10-13 displays examples of PPE. The skin,
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mucous membranes, and nonintact skin must be protected. Some facts about PPE include: ❖ Employers must provide PPE to all employees at no cost and it must be easily accessible. Employers must also clean, launder, and dispose of all PPE. ❖ Gloves must be worn when the hands could possibly come in contact with blood or OPIM, mucous membranes, and broken skin, and when performing phlebotomy. Gloves must be changed immediately if torn or punctured. If an employee is allergic to latex, the employer must provide an alternate type of gloves. ❖ Masks, eye protection, and face shields must be used when there is a possibility of splashing or spraying of blood or OPIM. The eyes, nose, and mouth must be protected. Glasses alone are not considered sufficient protection for the eyes. ❖ Gowns, aprons, or lab coats must be worn to protect clothing from exposure. All PPE must be removed and placed in appropriate containers before leaving the workplace. FIGURE 10-12 An emergency eye wash station provides a continuous flow of water to flush the eyes of toxic or hazardous chemicals or materials.
FIGURE 10-13 Some examples of personal protective equipment (PPE)
Engineering controls (devices used to separate employees from hazards) and work practice controls (methods by which a task is performed) are the means
PRINCIPLES OF INFECTION CONTR OL AND OSHA STANDARDS
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The CDC has estimated that more than 600,000 percutaneous injuries from contaminated sharps occur annually among health care workers. Onethird of these injuries occur during disposal. Because of these statistics, Congress sponsored the Needlestick Safety and Prevention Act of 2000. The act directed OSHA to revise the Bloodborne Pathogens Standard requiring employers to use safer and more effective medical devices. Employers must evaluate and implement the use of safer medical devices, must document and involve nonmanagerial front-line employees in evaluating and choosing the safer devices, and must maintain a sharps injury log. The log must contain the following information: (1) type
used to minimize or eliminate employee exposure. These controls deal with the use of safer equipment and mechanical devices such as retractable needles, shielded needles, and plastic capillary tubes. Sharps containers also fall under the category of engineering controls. These containers must be puncture-resistant, leakproof on the sides and bottom, color-coded, and labeled (Figure 10-14). The following is a list of engineering controls and work practice controls that should be instituted when working in medical establishments: ❖ Eating, drinking, smoking, applying cosmetics, and handling contact lenses is prohibited in any area where exposure is likely.
FIGURE 10-14 Examples of different types of sharps containers. The biohazard symbol must be clearly displayed on the container.
and brand of device involved in the incident; (2) location of the incident, work area, or department; and (3) description of the incident. To comply with the new OSHA standard, manufacturers have developed new devices (see Chapters 26 and 33 for examples), such as: ❖ Syringes with protective shields that cover the needle ❖ Needles that retract into the barrel of the syringe after use ❖ Plastic blood collection tubes ❖ Self-blunting needles ❖ Retracting lancets
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F IELD SM A RTS
❖ Food and drinks must not be stored in the same refrigerators, on shelves, or in cabinets used for the storage of blood or OPIM. ❖ Mouth pipetting is prohibited. ❖ Specimens of blood and OPIM must be placed in properly labeled containers identified as biohazardous. These containers must be leakproof for safe handling and transport. ❖ Never clean up broken glass with your hands. Dustpans, brushes, tongs, or forceps should be used and the glass must be placed in a sharps container.
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C R I T I C A L T H I N K I NG CHALLENGE While cleaning the exam room after a minor surgical procedure, you accidentally stick your thumb with a sharp probe that the provider used on the patient. The patient is HIV positive. 1. What should be your first step in the process following a needlestick incident? 2. What prophylactic medications can be given to you? 3. How long may it take before you produce a positive antibody test for HIV? (Refer to “Hepatitis B Vaccination, Postexposure Evaluation, and Follow-Up” later in this chapter for more information.)
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❖ Never recap a contaminated needle. If you must recap, use one-handed scoop technique. ❖ Never reach into a sharps container with your hands. ❖ All equipment and work surfaces must be cleaned and decontaminated after exposure to blood and OPIM. An appropriate disinfectant must be used. ❖ Equipment must be decontaminated before servicing. If an area cannot be cleaned, it must be clearly labeled to prevent exposure. Regulated waste—also known as infectious waste—is any medical waste contaminated with blood, body fluids, or OPIM. According to the Bloodborne Pathogens Standard, regulated waste includes: (1) liquid or semiliquid blood or OPIM; (2) any item contaminated with blood or OPIM that if squeezed would release the blood or OPIM; (3) any item caked with dried blood or OPIM that would flake off if han-
FIGURE 10-15 The medical assistant properly cleans up a specimen spill, wearing gloves and disposing of all contaminated materials in the biohazard bag.
dled; (4) contaminated sharps; and (5) any pathology or microbiology wastes that contain blood or OPIM. When cleaning spills that involve regulated waste, gloves must be worn, and all contaminated materials from the clean-up process must be placed in a biohazard bag (Figure 10-15). Other guidelines include: ❖ All contaminated sharps must be disposed of immediately in approved sharps containers that are easily accessible. Sharps containers should always remain upright and should not be overfilled. If the outside of the sharps container becomes contaminated, it should be placed inside a second container to prevent leakage. ❖ Approved biohazard containers, such as the one shown in Figure 10-16, must be used to store all regulated waste. ❖ Contaminated laundry should not be handled more than necessary and must be placed in a
FIGURE 10-16 The medical assistant assembles a biohazard waste container to be used for disposal of infectious waste.
PRINCIPLES OF INFECTION CONTR OL AND OSHA STANDARDS
clearly labeled bag or container. If the laundry is wet, it must be double-bagged or placed in a second leakproof container. ❖ Employees must wear eye protection along with other appropriate PPE when handling contaminated laundry. Refer to Table 10-6 for specific guidelines for the proper disposal of biohazardous waste. Important note: Table 10-6 follows OSHA guidelines; however, disposal guidelines may vary from one facility to another. When following Standard Precautions, anything that has any type of a body fluid on it or in it regardless of the amount should be placed in the biohazardous trash. Employers must maintain a clean and sanitary work environment and should have a written schedule for cleaning and decontamination. All work surfaces that become contaminated with blood and OPIM must be decontaminated following use, especially at the end of the workday. Gloves must be worn when cleaning any
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surface that may be contaminated with blood or OPIM. A 10% solution of bleach is an effective disinfectant. Paper towels and gloves should be used when cleaning a spill and then placed in an appropriate biohazard container.
Hepatitis B Vaccination, Postexposure Evaluation, and Follow-Up Employers must provide all employees at risk for occupational exposure to blood and OPIM with the HBV vaccine free of charge and at a convenient time and place. The vaccine is administered intramuscularly in three doses. The recommended schedule is the initial injection, followed by the second injection one month later, and the third injection five months following the second injection. Statistics confirm a 98% effectiveness rate in adults who have the series. In the event that an employee refuses the vaccine, she must sign a declination form, which must be kept on file. The employee may decide to be vaccinated at a later date, also at the employer’s expense.
TABLE 10-6 OSHA Guidelines for Proper Disposal of Biohazardous Waste
CLASS OF WASTE
BIOHAZARD CONTAINER WITH RED BAG
Blood, blood products, plastic vials of blood, microbiology specimens for culture, used culture plates and culture tubes
X
Containers of CSF, synovial, pleural, peritoneal, pericardial, or amniotic fluid
X
Fluid-filled containers from patient
X
Surgical pathology specimens
X
SHARPS CONTAINER
Needle/syringe units, needles, scalpels, suture needles, etc.
X
Glass slides and cover slips, pipettes, glass tubes of blood, microhematocrit tubes
X
REGULAR TRASH
Used urine, stool, and other specimen containers, peripads, diapers, chux, and empty urinary drainage bags
X
Dressings, bandages, cotton balls, and cotton swabs, unless saturated with blood or OPIM
X
Used gloves, aprons, masks, and shoe and head covers, unless saturated with blood or OPIM
X
Paper towels used for handwashing, food waste, computer paper, and packaging materials
X
Materials used to clean up nonhazardous spills
X
Note: Aways check facility guidelines before disposing of biohazardous wastes.
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Should exposure to blood, body fluids, or OPIM occur, the following steps should be taken: ❖ The wound or exposed area should be immediately cleansed with soap and water, and if necessary, covered with a sterile bandage. ❖ If the eyes are contaminated, they should be flushed with tepid water for several minutes. ❖ If mucous membranes, such as the mouth, are contaminated, they should be rinsed with water or mouthwash. ❖ After first-aid measures have been instituted, the exposure should be reported to the immediate supervisor. ❖ An exposure report form must be completed and filed. ❖ The exposed employee should be tested for HBV and HIV (the employee must give consent to be tested). ❖ The source or individual whose blood was involved in the exposure must give permission for her blood to be tested for HBV and HIV. If permission is granted by the source individual, the employee is permitted to know the results. ❖ The exposed employee should be offered gamma globulin or other preventative medications. ❖ The exposed employee should be offered counseling both to alert the employee regarding precautions to avoid further transmission to others and for stress management.
Recordkeeping Medical records associated with the exposure incident must be kept separate from the employee’s personnel record and must be on file for the length of employment plus 30 years. The employer must provide the exposed employee with a written report from the treating provider within 15 days following testing. The employee must be informed of the results of all postexposure tests and evaluations including any conditions that may require follow-up, treatment, and evaluation. Records are confidential but must be available to OSHA, the
employee, and anyone with the employee’s written permission. Employers must provide training for all at-risk employees at the time they assume their duties and annually after that. Anytime an employee’s job description or duties change, retraining is required. All training sessions must be documented and placed on file for three years. Employee training programs should include: ❖ Full description and explanation of the Bloodborne Pathogens Standard, symptoms of bloodborne diseases, and means of transmission ❖ Step-by-step explanation of the exposure control plan ❖ Engineering and work practice controls ❖ PPE to be used ❖ HBV vaccination information ❖ Postexposure procedures ❖ Information explaining postexposure evaluation ❖ Information explaining the biohazard label and color-coding of containers
The Biohazard Label The biohazard label alerts everyone to the presence of actual and potential biological hazards (Figure 10-17). It must be placed on all containers and BIOHAZARD in all areas where exposure to blood, body fluids, and OPIM is possible. Anything contaminated with blood, INFECTIOUS WASTE body fluids, or OPIM—including gloves, gowns, masks, gauze, wipes, etc.—must be labeled as a biohazard FIGURE 10-17 and placed in an appropriate container. A biohazard label. Biohazard label requirements include: ❖ The label must be fluorescent orange or red in color. ❖ The biohazard symbol must appear on the label. ❖ The label must be secured to all containers. ❖ Red bags or containers may be used in place of the biohazard label. ❖ Refrigerators used to store blood, blood products, body fluids, and OPIM must clearly display the biohazard label.
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S I T E C H EC K As a site reviewer, I will inspect the eyewash station to ensure proper connection to the plumbing. Eyewash water temperature should not exceed 100°F (37°C) and a log must be maintained to show weekly/monthly inspections.
EXPOSURE TO HAZARDOUS CHEMICALS Medical assistants not only face the possibility of exposure to biological hazards but may be exposed to hazardous chemicals as well. Many chemicals are used in the laboratory. Exposure can occur through inhalation, injection, or by direct contact to skin. The medical assistant must be aware of these hazards and the
PRINCIPLES OF INFECTION CONTR OL AND OSHA STANDARDS
guidelines for proper handling, storage, and disposal of hazardous chemicals.
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Chemical Hygiene Plan
ous chemicals are acetone, formaldehyde, bleach, ethyl alcohol, blood and tissue stains, tissue fixatives, and chemotherapeutic agents. Standards for a chemical exposure plan include:
A written chemical hygiene plan is required by OSHA and must be in place to provide information and training in facilities where chemicals are stored and handled by employees. Compliance is not optional—it is the law. Some labs are not required to adhere to these standards if the test methods used in the particular lab do not put employees at risk for exposure to hazardous chemicals, such as dipstick procedures or test kits that contain sealed chemicals. Some examples of hazard-
❖ Inventory of all hazardous chemicals that lists chemical name, quantity, physical state, hazard class, and manufacturer ❖ A material safety data sheet (MSDS) manual should be available to all employees. Information can be obtained from the manufacturer. All MSDS must be in alphabetical order within the manual (Figure 10-18). All information must be reviewed and revised on a regular basis. Figure 10-19 shows
FIGURE 10-18 MATERIAL SAFETY DATA SHEET
I – PRODUCT IDENTIFICATION COMPANY NAME: We Wash Inc.
ADDRESS: 5035 Manchester Avenue Freedom, Texas 79430
Te l No: (314) 621-1818 Nights: (314) 621-1399 CHEMTREC: (800) 424-9343
PRODUCT NAME: Spotfree
Product No.: 2190
Synonyms: Warewashing Detergent
II – HAZARDOUS INGREDIENTS OF MIXTURES MATERIAL:
(CAS#)
% By Wt.
TLV
PEL
According to the OSHA Hazard Communication Standard, 29CFR 1910.1200, this product contains no hazardous ingredients.
N/A
N/A
NA
III – PHYSICAL DATA Vapor Pressure, mm Hg: N/A Evaporation Rate (ether=1): N/A Solubility in H2O: Complete Freezing Point F: N/A Boiling Point F: N/A Specific Gravity H2O=1 @25C: N/A
Vapor Density (Air=1) 60–90F: N/A % Volatile by wt N/A pH @ 1% Solution 9.3–9.8 pH as Distributed: N/A Appearance: Off-White granular powder Odor: Mild Chemical Odor
IV – FIRE AND EXPLOSION Flash Point F: N/AV
Flammable Limits: N/A
Extinguishing Media: The product is not flammable or combustible. Use media appropriate for the primary source of fire. Special Fire Fighting Procedures: Use caution when fighting any fire involving chemicals. A self-contained breathing apparatus is essential. Unusual Fire and Explosion Hazards: None Known
V – REACTIVITY DATA Stability - Conditions to avoid: None Known Incompatibility: Contact of carbonates or bicarbonates with acids can release large quantities of carbon dioxide and heat. Hazardous Decomposition Products: In fire situations heat decomposition may result in the release of sulfur oxides. Conditions Contributing to Hazardous Polymerization: N/ A
A material safety data sheet (MSDS) containing all pertinent data on the product or chemical (Courtesy of POL Consultants, 2 Russ Farm Way, Delanco, NJ 08075, 856-824-0800.) (continues on next page)
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Spotfree VI – HEALTH HAZARD DATA EFFECTS OF OVEREXPOSURE (Medical Conditions Aggravated/Target Organ Effects) A. ACUTE (Primary Route of Exposure) EYES: Product granules may cause mechanical irritation to eyes. SKIN (Primary Route of Exposure): Prolonged repeated contact with skin may result in drying of skin. INGESTION: Not expected to be toxic if swallowed, however, gastrointestinal discomfort may occur. B. SUBCHRONIC, CHRONIC, OTHER: None known.
VII – EMERGENCY AND FIRST AID PROCEDURES EYES: In case of contact, flush thoroughly with water for 15 minutes. Get medical attention if irritation persists. SKIN: Flush any dry Spotfree from skin with flowing water. Always wash hands after use. INGESTION: If swallowed, drink large quantities of water and call a physician.
VIII – SPILL OR LEAK PROCEDURES Spill Management: Sweep up material and repackage if possible. Spill residue may be flushed to the sewer with water.
Waste Disposal Methods: Dispose of in accordance with federal, state and local regulations.
IX – PROTECTION INFORMATION/CONTROL MEASURES Respiratory: None needed
Eye: Safety glasses
Glove: Not required
Other Clothing and Equipment: None required Ventilation: Normal
X – SPECIAL PRECAUTIONS Precautions to be taken in Handling and Storing: Avoid contact with eyes. Avoid prolonged or repeated contact with skin. Wash thoroughly after handling. Keep container closed when not in use. Additional Information: Store away from acids. Prepared by: D. Martinez
Revision Date: 04/11/XX
Seller makes no warranty, expressed or implied, concerning the use of this product other than indicated on the label. Buyer assumes all risk of use and/or handling of this material when such use and/or handling is contrary to label instructions.
FIGURE 10-18
While Seller believes that the information contained herein is accurate, such information is offered solely for its customers’ consideration and verification under their specific use conditions. This information is not to be deemed a warranty or representation of any kind for which Seller assumes legal responsibility.
(continued)
an example of a chemical inventory form that should be used to list all chemicals stored on the premises. ❖ All chemicals are labeled according to the National Fire Protection Association’s color and number method. Figure 10-20 illustrates an example of the NFPA 704M Label and the HMIS Label for labeling hazardous chemicals. There are only slight variations between the two. Both are color-coded with a numerical value assigned to each category denoting the level of hazard present. Each color represents a specific hazard:
❖ Blue = health hazard ❖ Red = fire hazard ❖ Yellow = reactivity hazard ❖ White = PPE ❖ All employees must participate in a training program within 30 days of the start of employment or before handling hazardous chemicals. The program must provide information on location and storage of hazardous chemicals, reading and understanding chemical labels, location of MSDS manual, PPE required, and directions on how to clean up a chemical spill.
PRINCIPLES OF INFECTION CONTR OL AND OSHA STANDARDS
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NFPA 704M LABEL REACTIVITY HAZARD
HAZARDOUS CHEMICALS INVENTORY LIST Chemical Name
Quantity
Physical State
Hazard Class
FIRE HAZARD 4 3 2 1 0
Manufacturer Comments
4 3 2 1 0
- Very Flammable - Readily Ignitable - Ignited with Heat - Combustible - Will not Burn
HEALTH HAZARD 4 3 2 1 0
-
Deadly Extreme Danger Hazardous Slightly Hazardous Normal Materials
SPECIAL
- May Detonate - Shock & Heat May Detonate - Violent Chemical Change - Unstable if Heated - Stable
SPECIFIC HAZARD OXY - Oxidizer ACID - Acid ALK - Alkali COR - Corrosive W - Use no Water
FIGURE 10-20a The National Fire Prevention Association’s color and number method for labeling hazardous chemicals
HMIS LABEL HEALTH HAZARD 4 3 2 1 0
*
Deadly Extreme Danger Hazardous Slightly Hazardous Normal Materials Chronic Hazard
REACTIVITY HAZARD
FIGURE 10-19 A sample hazardous chemicals inventory list
4 - May Detonate 3 - Shock & Heat May Detonate 2 - Violent Chemical Change 1 - Unstable if Heated 0 - Stable
FIRE HAZARD 4 3 2 1 0
- Very Flammable - Readily Ignitable - Ignited with Heat - Combustible - Will not Burn
PERSONAL PROTECTIVE EQUIPMENT RECOMMENDATIONS
FIGURE 10-20b HMIS hazardous chemical labeling method
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E M R A P P L I C AT I O N Some EMR software programs stock their material safety data sheets within the EMR as well as the lab. This allows the forms to be easily accessed by all persons working in the practice.
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SITE C H E C K As a site inspector, I will not only be inspecting the facility itself, but also all required OSHA records. Complete records must be kept documenting current OSHA training and MSDS training for all current employees.
SAFEGUARDS IN THE EDUCATIONAL ENVIRONMENT Students involved in an educational program do not fall under OSHA guidelines (students are not considered to be in the same category as an employee). However, all necessary precautions should be performed in the educational setting to safeguard students against exposure to potentially infectious blood and body fluids as well as hazardous chemicals. Students should practice Standard Precautions and use PPE when handling biological samples in the classroom and lab. They should also be aware of the location of the OSHA and MSDS manuals, the location of hazardous chemicals, and the procedure for cleaning up a chemical spill.
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PROCEDURE 10-1 Perform Medically Aseptic Handwashing Objective: To cleanse the hands and wrists of surface bacteria to reduce or prevent the spread of pathogenic microorganisms.
Equipment/Supplies: ❖ Soap (preferably liquid) ❖ Sink
❖ Paper towels ❖ Orange stick
PROCEDURAL STEPS
RATIONALE
1. Remove all jewelry (except plain wedding bands).
Microorganisms can hide in crevices in jewelry.
2. Stand at the sink, but do not touch the rim of the sink with hands or clothing.
The sink is considered contaminated.
3. Turn on the faucet with a paper towel, adjust the water temperature, and discard the towel (Figure 10-21a).
Faucets are considered contaminated; water temperature should be warm, not hot.
4. Wet the hands, wrists, and forearms and apply soap; using a circular motion and friction, scrub the backs and palms of hands, wrists, and forearms, interlace fingers and thumbs and rub back and forth to clean surfaces in-between; keep the hands pointing down during the entire washing process (Figures 10-21b and c).
Friction and running water are best for cleansing; by keeping hands pointed downward and lower than the forearms, contaminants run off the hands and down the drain, instead of back up onto the clean forearm.
5. For the first handwashing of the day, clean the nails and cuticles with an orange stick or soft brush (Figures 10-21d and e).
Microorganisms can collect under the nails (especially acrylic and adorned nails) and around the cuticles.
6. Rinse the hands and wrists well with the hands pointed downward (Figure 10-21f).
Keeps dirty water and soap from running back over clean hands and wrists.
7. Repeat the handwashing steps if this is the first handwashing of the day or when the hands are contaminated with blood or OPIM. 8. Blot the hands, wrists, and forearms dry with a paper towel and discard the towel. Turn the faucet off with a clean paper towel.
Rubbing the skin with a towel can cause irritation. Touching the faucet will contaminate clean hands.
9. Apply antibacterial lotion.
Continuous handwashing causes irritation and chapping to the hands.
PRINCIPLES OF INFECTION CONTR OL AND OSHA STANDARDS
FIGURE 10-21a Prepare paper towels, use a towel to turn on the faucet, and adjust the water temperature.
FIGURE 10-21d Use an orange stick to clean under the fingernails and around the cuticles for the first washing of the day.
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FIGURE 10-21b Wet the hands, keeping the hands pointed downward, and apply soap.
FIGURE 10-21c Wash the backs and palms of the hands using a circular motion, interlacing fingers to clean between them.
FIGURE 10-21e A soft brush may also
FIGURE 10-21f Rinse the hands with the fingers pointing downward.
be used to clean under the fingernails.
PROCEDURE 10-2 Perform an Alcohol-Based Hand Rub Objective: To properly perform an alcohol-based hand rub according to the CDC’s guidelines for hand hygiene.
Equipment/Supplies: ❖ Alcohol-based hand rub PROCEDURAL STEPS
RATIONALE
1. Inspect the hands for any visible soil or contamination. If present, the hands must be washed first.
An alcohol-based hand rub is not used to remove soil from the hands.
2. Remove all jewelry (except plain wedding bands).
Jewelry can harbor microorganisms.
3. Apply the recommended amount of alcohol-based hand rub (Figure 10-22a).
Gels and lotions require a smaller amount than foam. Overapplication is not needed to achieve optimum results.
4. Smooth the hand rub over all surfaces of the hand.
All areas must be coated to ensure that no areas remain contaminated.
5. Rub the hands together (approximately 15 to 30 seconds) until dry (Figure 10-22b).
Moist hands could attract microorganisms. continues
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continued
FIGURE 10-22a Apply the appropriate amount of alcoholbased hand rub.
FIGURE 10-22b Rub the hands together until all the hand rub is absorbed into the skin.
PROCEDURE 10-3 Remove Contaminated Gloves Objective: To properly remove and dispose of contaminated gloves and lessen the possibility of exposure.
Equipment/Supplies: ❖ Biohazard waste container PROCEDURAL STEPS
RATIONALE
1. With the hands pointed downward and away from the body, grab the palm of the left glove with the right hand (Figure 10-23a).
By keeping the hands pointed downward and away from the body, the risk of exposure to biohazardous material is reduced.
2. Turn the left glove inside out and crumple it into a ball in the right hand (Figure 10-23b, c, d, and e).
Turning the glove inside out places contaminants on the inside and away from the body.
3. While grasping the contaminated glove that has been removed in the gloved hand, insert two fingers of the ungloved hand between the wrist and under the cuff of the contaminated glove (Figure 10-23f).
By inserting ungloved fingers under the cuff, contact with the outside of the contaminated glove is avoided.
4. Turn the right glove inside out over the other glove (Figures 10-23g and h).
Contaminated surfaces of both gloves are reversed and the gloves can be handled without risk of exposure.
5. Dispose of the contaminated gloves in a biohazard waste container (Figure 10-23i).
Contaminated gloves should be placed in a red, waterproof biohazard bag.
6. Wash the hands.
Washing the hands after removing gloves removes possible contamination and powder left behind from inside the gloves.
PRINCIPLES OF INFECTION CONTR OL AND OSHA STANDARDS
FIGURE 10-23a Grasp the palm of the contaminated left glove with the right hand.
FIGURES 10-23b, c, and d Remove the left glove, turning it inside out.
FIGURE 10-23e Crumple
FIGURE 10-23f Insert two fingers of the ungloved hand between the wrist and under the cuff of the contaminated glove.
the contaminated glove and hold it in the right hand.
FIGURE 10-23g Turn the contaminated glove inside out over the other glove.
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FIGURE 10-23h The contaminated surfaces of both gloves are inside.
FIGURE 10-23i Dispose of the gloves in a biohazard container.
Chapter Summary Working in the medical field can be a very rewarding occupation; however, it does not come without certain risks to the health care worker. Medical assistants may be exposed to biohazards and infectious diseases on a daily basis, but can protect themselves by following Standard Precautions. OSHA and the CDC have worked together for many years to make the work environment a safer place for health care workers and patients alike. Standards and guidelines have been developed to decrease the number of occupational exposure incidents and to prevent the spread of disease. By adhering to these guidelines, health care workers can provide the safest care for their patients and themselves.
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FIELD APPLICATION CHALLENGE You are a medical assistant employed in a multiprovider family practice office. You are responsible for performing all venipunctures and processing all specimens for transport to the laboratory. While performing a routine venipuncture, you must use several vacuum tubes before finding one that will fill completely with blood. After successfully obtaining the sample, you prepare the specimen to be sent
to the lab. As you are cleaning the work area, you inadvertently drop the full tube of blood into the sharps container along with the defective tubes. The patient has already left the office. 1. What should you do first? 2. How will you get a specimen to send to the lab?
Chapter Assessment 1. The branch of science that studies the frequency and distribution of disease is: a. demiology. b. epidemiology. c. pathology. d. virology.
6. The disease posing the greatest risk to health care workers is: a. AIDS. b. HIV. c. hepatitis C. d. hepatitis B.
2. The stage of infection that produces no identifiable signs or symptoms is: a. incubation stage. b. acute stage. c. invasion and multiplication stage. d. prodromal stage.
7. The primary means of spreading AIDS is: a. sharing eating utensils. b. sexual contact. c. kissing. d. none of the above.
3. The destruction of microorganisms before they enter the body is known as: a. sterilization. b. medical asepsis. c. surgical asepsis. d. disinfection. 4. Standard Precautions and Transmission-Based Precautions were developed by: a. OSHA. b. DDC. c. CDC. d. HHS. 5. Standard Precautions should be observed for: a. tissue specimens. b. CSF. c. blood. d. all of the above.
8. Barriers used to protect health workers from possible exposure to infectious agents are known as: a. safety hoods. b. Standard Precautions. c. work practice controls. d. PPE. 9. Regulated waste would include all of the following except: a. contaminated sharps. b. tubes containing blood. c. glass slides. d. contaminated dressings.
PRINCIPLES OF INFECTION CONTR OL AND OSHA STANDARDS
Web Activities 1. Check the CDC’s Web site (www.cdc.gov) for the latest information on hepatitis and AIDS prevention. 2. Log onto www.osha.gov to find the most current information on needlestick regulations and examples of new logs to be completed.
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THE DVD LINK On your StudyWARE CD-ROM, go to the DVD Challenge for this chapter. View the DVD clip and respond to the following questions: 1. What are two ways in which pathogens are transmitted from one individual to another? List examples of each.
CONNECTION Using your StudyWARE CD-ROM: ❖ Complete the Hangman and Concentration activities for this chapter. ❖ Complete the Quiz for this chapter in Test Mode.
2. How would you feel if someone like Mr. Breech came into your office and started coughing and contaminating the area in which you are working? 3. Obviously patients can’t help it when they have to cough or sneeze, but what are two different precautions Mr. Breech might have instituted to reduce the spread of microorganisms when he coughed?
C H A P T E R
Basic Vital Signs and Measurements Chapter Outline Introduction to the Patient Screening the Patient The Patient Intake Height and Weight BMI or Body Fat Percentage Vital Signs Temperature
Pulse Respiration Blood Pressure Pain Assessment Pulse Oximetry
Developmental Objectives After completing this chapter, you should be able to: 1. Correctly spell and define essential terms. 2. Explain the purpose for obtaining a height and weight. 3. List the vital signs, the reasons for obtaining them, and the normal ranges for each. 4. Describe the mechanisms that may cause variations in vital signs. 5. List the sites available for obtaining a temperature and the specific reasons for taking measurements at each site. 6. Identify the different pulse points. 7. Define blood pressure and the meaning of systole and diastole.
11 Essential Terms afebrile arrhythmia baseline body mass index (BMI) bradycardia bradypnea calipers Celsius (C) diastole diastolic pressure diurnal rhythms dyspnea dysrhythmia exhalation expiration Fahrenheit (F) febrile fever homeostasis hyperpnea hypertension hyperthermia continues
BASIC VITAL SIGNS AND MEASUREMENTS
KEY COMPETENCIES
❖
CAAHEP
ABHES
Obtaining a Height and Weight on an Adult Patient
III.C.3.b.4.b
VI.A.1.a.4.d
Obtaining an Oral Body Temperature
III.C.3.b.4.b
VI.A.1.a.4.d
Obtaining an Aural Body Temperature
III.C.3.b.4.b
VI.A.1.a.4.d
Obtaining an Axillary Body Temperature
III.C.3.b.4.b
VI.A.1.a.4.d
Obtaining a Temporal Artery Body Temperature
III.C.3.b.4.b
VI.A.1.a.4.d
Obtaining a Radial Pulse Rate and Respiration Rate
III.C.3.b.4.b
VI.A.1.a.4.d
Obtaining an Apical Pulse Rate
III.C.3.b.4.b
VI.A.1.a.4.d
Obtaining a Blood Pressure (Palpatory Method)
III.C.3.b.4.b
VI.A.1.a.4.d
hyperventilation hypotension hypothermia inhalation inspiration Korotkoff sounds mensuration metabolism obesity orthopnea orthostatic hypotension pulse pressure pulse rate pulse rhythm pulse volume radiate respiration sphygmomanometer systole systolic pressure tachycardia tachypnea vasoconstriction vasodilation vital signs
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Introduction Obtaining accurate vital signs is an important role of the medical assistant. Physical changes that occur in the body from one visit to the next may be detected through a change in a patient’s vital signs. Vital signs, also known as cardinal signs, include temperature, pulse, and respiration (these three vital signs as referred together as TPR), and blood pressure (BP). Some medical references now include pain assessment as a fifth vital sign. Other measurements that may be taken in addition to vital signs include the patient’s height and weight and the patient’s oxygen saturation level. Customarily, all vital signs are obtained during a patient’s initial visit to determine baseline readings. Whether or not all vital signs are performed during each subsequent visit will depend on the type of specialty, the provider’s preferences, and the patient’s symptoms. Accurate measurements should be taken and the results recorded in the patient’s chart. Medical assisting students should practice vital signs regularly to become proficient at these procedures prior to entering the workplace.
INTRODUCTION TO THE PATIENT The first contact a medical assistant has with the patient occurs when the patient is summoned from the reception area to the examination room. The medical assistant must be aware of office policies for properly addressing patients in the waiting area. Most clinics prefer that medical assistants call patients by their title (Mr., Mrs., Miss, Ms.,) and last name, unless patients specifically request to be called by their first name. Some older patients may find it disrespectful to be addressed by their first name by a younger individual. Ask patients directly how they would prefer to be addressed. Record this information in a special area of the patient’s chart so that all office staff members will know how to address the patient during future encounters.
Screening the Patient The medical assistant should use all senses during the initial screening process to gather important clues about the patient’s health status. The patient should be observed for the following:
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H I PA A PAT R O L According to HIPAA guidelines, it is permissible to use both the patient’s first and last name when calling the patient back to the examination room. You should not ask patients to verify any other personal information in front of other patients, such as demographic changes, insurance changes, or information about prior providers.
❖ ❖ ❖ ❖ ❖
Appearance Gait (a person’s manner of walking) Odors Level of awareness Emotional state
The medical assistant may make particular observations that the provider may not be able to observe, such as any difficulty the patient experiences while walking from the reception room to the examination room. Patients may express anxiousness or fearfulness to the medical assistant about a particular procedure or examination during the screening process. Sharing this information ahead of time with the provider will assist the provider in knowing how to proceed with the patient.
❖ ❖ ❖ ❖
Reason for the visit (chief complaint) Patient history or an update of history information Height and weight Vital signs
If no specimens are required, allow the patient time to use the restroom prior to examination so he will be more comfortable during the exam. If a urine specimen is necessary, provide the patient with the appropriate supplies and instructions for properly collecting a urine specimen. Store the specimen appropriately until testing can be performed. The medical assistant should be certain to accurately document all findings collected during the initial screening into the patient’s chart.
HEIGHT AND WEIGHT Measuring the patient’s height and weight is often the responsibility of the medical assistant. Mensuration is a term that means measurement. Fluctuations in a patient’s height or weight could indicate a health disorder or illness; therefore, accuracy and consistency are important. The weight of a patient is usually monitored during each office visit. Height is routinely measured until the patient stops growing, but may be performed on adults for specific types of exams. Height is carefully monitored on female patients during and following menopause. This is largely due the effects that low estrogen levels have on bone density following menopause.
The Patient Intake The term patient intake describes the process of obtaining vital signs and measurements and conducting a brief patient interview. Information that should be collected during patient intake or the initial screening process may include any of the following:
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F IEL D S M A R T S Be certain to follow HIPAA guidelines when gathering health information from a patient. If it is standard protocol to collect patient data in an open triage area, make certain that other patients are not within hearing distance. If the triage area is particularly busy, it may be best to defer taking the patient’s complaint until the patient is in the examination room.
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P A T I E N T P E R S P E CT IV E “I really don’t want to tell this person why I’m here today. It’s too embarrassing to talk about and I would rather just tell the physician.” Some patients may be uncomfortable telling you the exact reason they are seeking medical attention. If the patient seems hesitant or withdrawn, ask for a general complaint and respond to the patient in a caring manner. If the patient does not feel comfortable sharing any information with you, do not probe, but instead reassure the patient that it is fine to wait until the provider is present to reveal symptoms. Alert the provider of the patient’s hesitancy to share the information prior to examination.
BASIC VITAL SIGNS AND MEASUREMENTS
There are several Web sites available that automatically calculate BMI once the appropriate data is entered. The CDC provides ranges for interpreting the BMI outcome: Less than 18.5 18.6–24.9 25.0–29.9 Greater than 30
BMI or Body Fat Percentage Body mass index (BMI) is a numerical correlation between a patient’s height and weight. Calculating the patient’s BMI may be the responsibility of the medical assistant, and should be documented along with the scale weight. To calculate a patient’s BMI, use the following formula:
Underweight Acceptable weight Overweight Obese
Waist Circumference Some practices may evaluate waist circumferences to determine obesity. Waist circumference is measured
FIGURE 11-1 BMI index and height and weight chart listing statistics for determining a person’s BMI (From www.niddk.nih.gov.)
Body Mass Index Table To use the table, find the appropriate height in the left-hand column labeled Height. Move across to a given weight. The number at the top of the column is the BMI at that height and weight. Pounds have been rounded off. 20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
96 99 102 106 109 113 116 120 124 127 131 135 139 143 147 151 155 160 164
100 104 107 111 115 118 122 126 130 134 138 142 146 150 154 159 163 168 172
105 109 112 116 120 124 128 132 136 140 144 149 153 157 162 166 171 176 180
110 114 118 122 126 130 134 138 142 146 151 155 160 165 169 174 179 184 189
115 119 123 127 131 135 140 144 148 153 158 162 167 172 177 182 186 192 197
119 124 128 132 136 141 145 150 155 159 164 169 174 179 184 189 194 200 205
124 128 133 137 142 146 151 156 161 166 171 176 181 186 191 197 202 208 213
129 133 138 143 147 152 157 162 167 172 177 182 188 193 199 204 210 216 221
134 138 143 148 153 158 163 168 173 178 184 189 195 200 206 212 218 224 230
138 143 148 153 158 163 169 174 179 185 190 196 202 208 213 219 225 232 238
143 148 153 158 164 169 174 180 186 191 197 203 209 215 221 227 233 240 246
148 153 158 164 169 175 180 186 192 198 204 210 216 222 228 235 241 248 254
153 158 163 169 175 180 186 192 198 204 210 216 222 229 235 242 249 256 263
158 163 168 174 180 186 192 198 204 211 216 223 229 236 242 250 256 264 271
162 168 174 180 186 191 197 204 210 217 223 230 236 243 250 257 264 272 279
167 173 179 185 191 197 204 210 216 223 230 236 243 250 258 265 272 279 287
172 178 184 190 196 203 209 216 223 230 236 243 250 257 265 272 280 287 295
177 183 189 195 202 208 215 222 229 236 243 250 257 265 272 280 287 295 304
181 188 194 201 207 214 221 228 235 242 249 257 264 272 279 288 295 303 312
186 193 199 206 213 220 227 234 241 249 256 263 271 279 287 295 303 311 320
191 198 204 211 218 225 232 240 247 255 262 270 278 286 294 302 311 319 328
Height (Inches) 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76
91 94 97 100 104 107 110 114 118 121 125 128 132 136 140 144 148 152 156
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❖ Multiply the patient’s weight (in pounds) by 703. ❖ Divide this total by the patient’s height (in inches). ❖ Divide this total by the patient's height (in inches) again and then round to the nearest whole number. ❖ The result is the patient’s BMI.
As obesity is an increasing problem in the United States, many recommendations on acceptable weights have been explored. Insurance companies and nutritional organizations produce “normal” or desirable weight charts, such as the one seen in Figure 11-1. These do not usually account for body fitness and muscle mass. Body mass index is a better indicator for weight as it relates to the patient’s health. Refer to Procedure 11-1 for instructions on performing height and weight on an adult patient. Refer to Chapter 19 for a procedure on performing these tasks on pediatric patients.
BMI 19
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Weight (Pounds)
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PA TIEN T P E R SP E C T I V E
C R I T I C A L T H I N K I NG CHALLENGE
I have been watching my dietary intake and working out more for several months now. When I first started the exercise program, I was losing weight at a steady pace. Now, my clothes are starting to fit better, but my weight is increasing. This is really getting frustrating. Maybe I should just forget this fitness stuff.
while the patient is in a standing position. A tape measure is placed around the patient’s waist just superior to the hip bone. When using waist circumference to establish excess body fat, the following applies: ❖ Measurements for a woman greater than 35 inches would be considered excessive. ❖ Measurements for a man greater than 40 inches would be considered excessive.
Body Fat Calipers A more accurate procedure for determining body fat is through the use of body fat calipers. Body fat calipers are devices that measure skinfolds on different parts of the patient’s body.
VITAL SIGNS Changes in a patient’s health can often be detected through the monitoring of vital signs. Other basic physiological measurements as well as any changes that have occurred since the patient’s last medical examination can provide an overall picture of the patient’s general state of health. Temperature, pulse, respiration, and blood pressure (TPR and BP) are standard vital signs taken. Any changes identified during measurement of these vital signs may indicate a health condition or may illustrate the progression of a previously identified medical condition. Obtaining vital signs when the patient is healthy or during an initial visit provides a baseline to which future vital signs can be compared. In addition to TPR and BP, a pain rating may also be obtained from a patient, especially in the hospital environment. Pulse oximetry (a measurement of the oxygen concentration in the blood) is also considered another key indicator of health status.
Refer to the Patient Perspective tool box on this page. 1. What might be causing the patient to gain weight even though he may be spending so much time working out? 2. What can you do to encourage the patient not to give up? 3. Some patients may not come right out and tell their frustrations. What nonverbal signs might indicate that the patient is getting frustrated?
Temperature Staying within a particular temperature range is essential for the body to maintain homeostasis (a state in which the body’s internal conditions are able to remain constant in the midst of changing environments). Tissues and cells in the body function best when the body’s temperature ranges between 97°F and 99°F (36.1°C and 37.2°C). Maintenance of a normal body temperature is necessary for an individual to remain in a healthy state.
Structures That Help Regulate Body Temperature Several structures or organs within the body work together to keep the body’s temperature regulated, including: ❖ The hypothalamus: This structure within the brain acts as a thermostat to control body temperature. ❖ Blood vessels: When the body is hot, vasodilation occurs—this is a mechanism in which cutaneous blood vessels dilate (or increase in diameter), allowing more blood to circulate toward the surface of the skin, and causing more heat to radiate outward. When the body is cold, vasoconstriction decreases the diameter of cutaneous blood vessels, causing blood vessels to sink and trap more heat within the body. ❖ The integumentary system (skin and pores): This system allows the body to lose heat through perspiration. ❖ The neuromuscular system: In conjunction with the nervous system, this system works to cause
BASIC VITAL SIGNS AND MEASUREMENTS
shivering, which helps raise body temperature in frigid conditions.
Heat Produced versus Heat Lost in the Body To maintain proper body temperature, the amount of heat generated within the body must be balanced with the amount of heat lost from the body. As body temperature rises, certain mechanisms occur to rid the body of excess heat. If body temperature dips too low, the body conserves heat. Table 11-1 shows some causes of heat production along with some causes of heat loss. If the amount of heat produced exceeds the amount lost, a fever occurs and the patient is considered febrile. If the amount of heat lost is greater than the amount of heat generated, hypothermia can occur. A patient with a normal body temperature is said to be afebrile. Normal or average body temperature is approximately 98.6°F (37°C), with allowances for mild fluctuations, as all individuals do not have exactly the same normal body temperature. Variations in temperature may occur as a result of environment, level of activity, and overall health. The time of the day may also influence a temperature reading, due to diurnal rhythms. Early morning temperatures taken around 4:00 a.m. tend to be lower than midday readings due to a decrease in metabolism and muscle contractions. Early morning readings can be as low as 96.4°F (35.8°C), while late afternoon and evening measurements taken around 8:00 p.m. may be normal at 99.1°F (37.3ºC). The way a temperature is taken will also affect the outcome; therefore, it is important to document the
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method by which the measurement was obtained. Rectal temperatures tend to run slightly higher than oral temperatures. Axillary temperatures run slightly lower than oral temperatures and are generally considered less accurate. Tympanic membrane, or aural (ear) temperatures, typically run higher than oral readings because they are within in a closed cavity.
Temperature Conversion The majority of medical offices in the United States use the Fahrenheit (F) scale to record a patient’s body temperature. However, some hospitals and governmental agencies as well as health care centers in other
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C R I T I C A L T H I N K I NG CHALLENGE You work for a pediatrician. A mother calls and says her six-year-old daughter has been sick for the past two days, with a fever ranging between 99°F and 101°F and that her temperature always seems to go up at night. The daughter isn’t complaining of any other symptoms, but the mother is concerned because of the night peaks. 1. What kind of information can you share with the mother that may help her feel more at ease?
TABLE 11-1 Body Heat Production and Heat Loss CAUSES OF HEAT PRODUCTION
CAUSES OF HEAT LOSS
Exercise: causes muscles to contract, generating heat within the body
Perspiration (sweating): heat leaves the body through moisture
Shivering: involuntary response to cold, causing muscle contraction, thus generating heat
Respiration: breathing out moisture containing heat
Metabolism: as nutrients are processed in the body, cells produce energy, which elevates body temperature
Excretion of urine and feces: heat is expelled through fluids in waste materials
Emotions (crying, rage, and anger): increase body temperature
Environmental conditions: exposure to frigid temperatures
Infection: cells produce heat when fighting infections Environmental conditions: excessive heat or excessive sun exposure Pregnancy and menses: may increase body temperature
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countries use the Celsius (C) scale. Use the following formulas when converting between these two scales: When converting from Celsius to Fahrenheit: Multiply the Celsius reading by 9/5 and add 32. Example: C ⫽ 36.1 ⫻ 9 ⫽ 324.9 ⫼ 5 ⫽ 64.98 ⫹ 32 ⫽ 97°F When converting from Fahrenheit to Celsius: Subtract the Fahrenheit reading by 32 and then multiply by 5/9. Example: F ⫽ 97 ⫺ 32 ⫽ 65 ⫻ 5 ⫽ 325 ⫼ 9 ⫽ 36.1°C Most electronic thermometers are able to display both Celsius and Fahrenheit readings.
Methods for Assessing the Body Temperature Temperatures can be taken in several locations on the body, including the mouth (orally), the armpit (axillary), the rectum (rectally), the ear (aurally or tympanic), and on the skin’s surface, such as the forehead. Oral Temperature Temperatures obtained in the mouth or oral cavity are usually obtained using an electronic digital thermometer (Figure 11-2). When taking an oral temperature, instruct the patient to refrain from biting down on the thermometer or probe. The blood supply under the tongue beside the frenulum linguae provides a good environment for temperature measurement. The vascular bed under the tongue is rich in blood supply and the air circulation within the oral cavity is diminished if the patient closes the lips around the thermometer and keeps them closed during the measurement. This ensures a more accurate core body temperature. FIGURE 11-2 Example of an electronic thermometer with both an oral (blue) and a rectal (red) probe
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FI E L D S M A R T S Normal temperature readings by route: Oral Aural Rectal Temporal Axillary
98.6°F 99.6°F 99.6°F 99.6°F 97.6°F
37.0°C 37.7°C 37.7°C 37.7°C 36.3°C
Notice how the aural, rectal, and temporal routes all have the same normal readings. This is because they are all considered core body temperatures because of their depth or proximity to a major artery.
Many factors can affect an accurate oral temperature reading such as: ❖ Eating or drinking: Lowers or raises the temperature of the mouth ❖ Smoking: Elevates temperature in the oral cavity ❖ Dental problems: Diseased gums or abscesses in the mouth can interfere with obtaining a true body temperature or make it difficult for the patient to hold the thermometer comfortably in the mouth. ❖ Sinus congestion or cold: Inability to breathe through the nose will cause the patient to try and breathe through the mouth, which interferes with the procedure. ❖ Unconsciousness: An unconscious patient is unable to maintain muscle control to hold the thermometer in the mouth. ❖ Lack of understanding: Very small children, elderly patients, or non-English-speaking patients may not understand the instructions for holding the thermometer in the mouth, or may not be able to control or coordinate the muscle movement necessary. Refer to Procedure 11-2 for the detailed steps and rationale for obtaining an oral temperature. Rectal Temperature The rectal method is considered one of the most accurate methods for taking body temperature because the rectum is the most closed cavity among all methods and there are fewer variables that can affect the readings. When compared with the oral temperature, rectal temperature readings are approximately 1 degree higher, with a normal reading of 99.6°F (37.7ºC). This method of measurement is
BASIC VITAL SIGNS AND MEASUREMENTS
used most often on younger children (when accuracy is imperative), unconscious patients, and on patients who might not be able to use other methods due to mobility or other health issues. This route is seldom used in the ambulatory health care setting. Safety is important when taking any temperature, but especially when taking rectal temperatures. When taking a rectal temperature, always hold the thermometer securely and do not allow the patient to move. The sphincter muscles of the rectum may cause involuntary movement of the thermometer, so a firm grip on the thermometer is necessary. Care should be taken to prevent trauma to the fragile muscosa when inserting the thermometer into the rectal cavity. Applying water-soluble lubricant to the thermometer will ease the insertion of the thermometer. Refer to Chapter 19 and Procedure 19-2 for details and rationale for obtaining a rectal temperature.
FIGURE 11-3 Thermo-scan tympanic thermometer (Courtesy of Welch Allyn.)
Aural Temperature Obtaining the body temperature through the ear canal (aural) is one of the most popular methods for taking body temperature. The aural or tympanic membrane thermometer (Figure 11-3) is relatively inexpensive and easy to use. The thermometer is inserted in the ear and a digital result is provided instantly. The thermometer sensor reads the heat emitted from the tympanic membrane (eardrum) as a core temperature. The aural route may be the preferred route when taking temperature on children, patients who are sleeping or unconscious, and on patients who cannot comply with using the oral method. The following lists conditions in which the aural method should not be used:
❖ When there is excessive cerumen (ear wax) in the ear ❖ When there is visible drainage coming from the ear, or the patient complains of ear pain or possible infection ❖ When the patient has bilateral hearing aids The proper placement of the tympanic membrane thermometer is essential for accuracy. The probe (covered with a disposable ear tip, as seen in Figure 11-4) should be inserted so that there is a tight seal, preventing external air from influencing the reading. The actual
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FIGURE 11-4 Disposable probe covers are used with the tympanic thermometer to prevent cross-contamination.
probe tip must point toward the tympanic membrane. Straightening the canal will assist in providing accurate results. For adults and children above the age of three, straighten the ear canal by gently pulling up and back on the auricle. For infants and children under the age of three, gently pulling the earlobe down and back will straighten the ear canal. Refer to Procedure 11-3 for the detailed steps for performing an aural temperature reading. Axillary Temperature The axillary temperature is the least accurate method for obtaining a body temperature and is only used when absolutely necessary. This method is commonly used on young children and those patients who are unable to hold a thermometer in their mouths. The thermometer is placed against the skin under the arm and held in place for the proper amount of time. An average axillary temperature reading is
TOOL BOX
FI E L D S M A R T S If the ear canal is not straightened properly or the probe tip is not inserted into right section of the canal while you are taking an aural temperature, the reading will be inaccurate. Another factor that may impact accuracy is the size of the probe tip in comparison to the diameter of the patient’s ear canal. If the tips do not match the size of the ear canal, a false reading may occur. Some offices take a reading in each ear and record the higher of the two.
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1 degree lower than an oral temperature reading. Procedure 11-4 lists the steps necessary to obtain an axillary temperature reading. Chemical Disposable Thermometers Disposable chemical indicator thermometers, such as the one shown in Figure 11-5, may also be used to determine body temperature. These thermometers may be used via the oral, rectal, or axillary routes. The plastic strip thermometer contains colored dots that will change color, indicating the temperature reading. Once the allotted time has elapsed, the dots are observed for change and the temperature is recorded. These thermometers must not be stored in areas with high temperatures and should be kept away from sunlight, or the thermometers will be ruined. Follow the storage and handling instructions on the box. Temporal Thermometers The latest technology available for determining core body temperature is the temporal thermometer (Figure 11-6). This device measures the temperature with a gentle stroke over the forehead. Because it is noninvasive and very easy to use, it is ideal for patients of all ages. Theoretically speaking, the best place to measure core body temperature would be at the center of the heart. A temporal thermometer reads the temperature over the temporal artery, which is connected to the heart by the carotid artery. The carotid artery bifurcates into the temporal and maxillary arteries. Since there is continuous blood flow through this area and the temporal artery lies close to the surface of the skin, it is easy to access and is thought to provide an accurate body temperature reading.
FIGURE 11-6 New temporal thermometers make it quick and easy to obtain a temperature reading, especially on infants and children.
When taking temperature by this method, the thermometer is gently moved over the center of the forehead and across the location of the temporal artery. The sensor scans the infrared heat given off by the blood flowing through the artery. The probe picks up the highest temperature of the area being scanned. There are some conflicting reports as to the accuracy of this route. Sweating from the skin can cool down the area being measured, which results in an inaccurate measurement. Because of this concern, an additional reading behind the ear below the mastoid process may be taken as well. The site with the highest reading should be recorded in the patient’s chart. Make certain that the forehead and temple region are bare, clean, and dry before using this method. Determining Temperature Method Determining which method will be used to obtain a temperature is dependent on several factors. Table 11-2 provides a summary of the various methods of measurement. The method chosen to measure temperature will depend on the particular needs of the individual patient and the protocol of the office, which is why medical assistants should be familiar with all methods for taking body temperature.
Fever
FIGURE 11-5 A chemical thermometer may be placed under the tongue or in the axilla. The color change of the dots indicates the temperature reading.
Fever, or pyrexia, is a temporary elevation in body temperature and usually results from infection. Fever is not a disease but rather a symptom of disease. Cells that assist with immunity break open and release pyrogens, which reset the body’s set-point for temperature. The increase in body temperature helps to destroy pathogens, thus aiding in the patient’s recovery. The
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TABLE 11-2 Advantages and Disadvantages of Each Method for Obtaining Body Temperatures METHOD (PROCEDURE)
ADVANTAGES
DISADVANTAGES
Oral (electronic)
Disposable sheaths Rapid measurement Easily accessible Usually comfortable for patient
Expensive Cannot be performed for patients with oral surgeries Cannot be performed for patients with seizures or who bite Is difficult for small children Can be affected by intake of fluids or smoking Is difficult and unreliable with rhinitis Presents a risk of exposure to body fluids
Aural (AU)/tympanic membrane (TM)
Accurate if properly performed Easily accessible Very rapid reading (1 to 5 seconds) Unaffected by oral intakes Can be used with unresponsive or sleeping patients
Requires removal of hearing aids Can be distorted if patient has otitis media or external otitis Excessive or impacted cerumen can alter reading Accuracy concerns if ear canal is not properly positioned
Rectal
Considered the most accurate of all routes
Not for use with patients who have had rectal surgery or diarrhea Can be embarrassing Can cause trauma if performed incorrectly Presents a risk of exposure to body fluids
Axilla
Safe and easy Noninvasive Easy with newborns
Not as accurate as other methods Requires more time to perform
Temporal
Noninvasive Safe and easy Quick Easily accessible Easy to use on all patients
Expensive Concerns regarding accuracy
new temperature set-point tricks the body into thinking it is in a state of hypothermia, which causes shivering and an increase in respiration, heart rate, and muscle tone. This effector response helps to elevate body temperature to the new temperature set-point. Once the pathogens have been destroyed, new cells are released that cause the temperature set-point to return the original set-point. The patient becomes very warm and the body starts to sweat, releasing trapped heat. Because of increased metabolism, infants and young children often spike higher temperatures than adults. Senior adults usually run lower temperatures because of a slower metabolism and may be very sick with elevations of only one or two degrees above normal body temperature.
Fevers may be classified as follows: ❖ ❖ ❖ ❖ ❖
Low-grade: 100.4°F–102.2°F (38°C–39°C) Moderate: 102.2°F–104.0°F (39°C–40°C) High-grade: 104.0°F–107.6°F (40°C–42°C) Hyperpyrexia: Greater than 107.6°F (42°C) Lethal: Greater than 109°F (43°C)
Causes of Fever Commonly, patients who present with a fever have some type of infectious process occurring within the body. Some common causes of fever are:
❖ Infections: Bacterial, viral, mycobacterial, fungal, parasitic ❖ Injury: Surgery, crush injuries
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It isn’t necessarily the actual temperature reading associated with the fever but rather the symptoms coinciding with the fever that are of most concern. Some patients with a body temperature of 103°F (39.4°C) may not appear very sickly while other patients with a body temperature of 101°F (38.3°C) may appear very ill. Adult patients and parents of pediatric patients should be educated on the benefits of fever as well as what to watch for in fever patients. Fever is the body’s way of fighting microorganisms that invade the body. Microorganisms live best at normal body temperature. Temperature
❖ Neoplasms: Lymphoma, leukemia, hepatic carcinoma ❖ Connective tissue disease: SLE, rheumatoid arthritis, vasculitis ❖ Malignant hyperthermia: Severe and rapid increase in body temperature ❖ Heatstroke ❖ Drug reactions The Course of a Fever There are some common terms used to describe the course of a fever. Table 11-3 lists those terms, along with their definitions.
TABLE 11-3 Terms That Describe Fever Patterns Continuous
Fever that remains elevated above the baseline, but does not fluctuate
Intermittent
Fever that comes and goes
Remittent
Fever that has peaks and drops but remains above normal
Lysis
Body temperature gradually returns to normal following a fever
Crisis
Body temperature abruptly decreases to normal, commonly referred to as the fever “breaking”
elevations work with the body’s immune system to destroy pathogens. Some experts now feel that patients should not take a fever reducer unless the fever climbs above 102°F (38.9°C) because it interferes with the immune response. Patients should be seen right away when a fever is in combination with listlessness, confusion, sore throat, breathing difficulties, headache and a stiff neck, urinary symptoms, blood in stool, swelling, or a red-hot swollen area of the skin. The reading at which you will bring a patient in for fever will vary according to the age of the patient and the patient’s general health.
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PAT I E N T T U T O R
When considering the core body temperature, an elevated temperature or fever is not the only possible outcome. A lowered body temperature, referred to as hypothermia, is considered lower than 97°F (36.1°C). Some common contributors to hypothermia include exposure to cold, decrease in movement (paralysis), excessive alcohol intake, starvation, hypothyroidism, and hypoglycemia. Refer to Chapter 35 to learn more about hypothermia.
Pulse As the heart contracts, it transports blood out of the ventricles and to the rest of the body. The force of the blood distends the walls of the aorta, creating a pulse that can be felt and evaluated at different points of the body (Figure 11-7). When the pulsation reaches the peripheral arteries, slightly pressing the artery with the pads of the index and middle finger against a nearby bone allows the medical assistant to feel a pulse. The rate, rhythm, and strength of the pulse are all assessed as part of taking pulse measurements. Table 11-4 lists the various sites where a pulse may be felt.
Pulse Characteristics When evaluating pulse or heart rate, it is important to not only count the number of times the heart beats per minute, but also to assess the rhythm and strength (volume) of the pulse. Procedure 11-5 provides steps and rationale for obtaining radial pulse and respiration rate. The pulse rate may be measured for 30 seconds and multiplied by two if the intervals between each
BASIC VITAL SIGNS AND MEASUREMENTS
Carotid artery
Temporal artery Apical
Brachial artery
Radial artery Femoral artery Popliteal artery (behind knee)
Dorsalis pedis artery
Posterior tibial artery
FIGURE 11-7 There are nine pulse points located on the body where the pulse can be felt and counted.
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beat are regular. If the intervals between beats are irregular, or the pulse rate is excessively low or high, pulse rate should be measured for a full minute. Normal rates, which vary in different age groups, are outlined in Table 11-5. Pulse rates normally decline with age. The average range for a healthy adult patient is generally 60 to 100 beats per minute (BPM), and is referred to as a normal sinus rhythm. Many factors can affect pulse rate including: ❖ Gender: The pulse rate in women tends to run a bit higher than the pulse rate of males. ❖ Level of fitness: Exercise not only improves muscle tone on the outside of the body but the heart as well. When the heart muscle is strong, it does not have to beat as fast to move blood around the body. ❖ Emotional status: Emotional states, such as fear and rage, temporarily raise pulse rate. ❖ Pregnancy: Because of increased metabolism, heart rate increases. ❖ Fever: Causes an increase in heart or pulse rate.
TABLE 11-4 Locations of Pulse Sites (in Anatomic Position) PULSE SITE
DESCRIPTION OF LOCATION/INDICATION
Temporal
Located in the temple region of the cranium; mainly used in emergency situations when patient is bleeding profusely from the head. It is also the artery that is involved in measuring temporal temperatures.
Apical
Located at the apex of the heart or at the fifth intercostal (between the ribs) space, just to the left of the midclavicular line. This site can be palpated or can be listened to with aid of a stethoscope and is commonly used to check pulse rate in infants and children up to the age of three.
Brachial
Located in the antecubital space, at the front side of the elbow. Commonly used to measure blood pressure in adults, as a checkpoint for pulse in infants while performing CPR, and is the artery that is compressed to control bleeding in the lower arm.
Carotid
Located just laterally to midline of the anterior neck. It is easy to palpate and is used as a checkpoint for pulse when performing CPR both in adults and in children. It is used to help control bleeding from the neck and lower head regions during hemorrhage situations.
Dorsalis pedis
Located on the superior surface of the foot and is often difficult to palpate. It is the site that is routinely used to assess circulation in the foot.
Femoral
Located in the center of the groin region. This artery is used to evaluate circulation in the lower extremities and to control bleeding in the lower leg.
Popliteal
Located on the posterior surface of the knee. May be used for blood pressures when brachial pulse is not accessible. It is most easily palpated when the knee is slightly bent.
Posterior tibial
Located on the medial aspect of the ankle, posterior to the ankle bone. It is used to evaluate circulation in the feet.
Radial
Located on the radial or thumb-side of the wrist, just superior to the thumb. The radial artery lies over the radius bone. It is the most common site for checking pulse rates in adults.
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TABLE 11-5 Pulse Rates
TOOL BOX
PATIENT POPULATION
AVERAGE PULSE RATE (BPM)
Newborn
140
0–6 months
130
6–12 months
115
12–24 months
110
2–6 years
100
Early school age
95
Adolescence through adulthood
80
Geriatric
74
Athletes
60
Elite athletes
50
FI E L D S M A R T S If you suspect an irregular rate or rhythm after taking a radial pulse, you should follow up by obtaining an apical pulse. This method of obtaining a pulse rate is generally easier to evaluate and more accurate in measurement.
thready. This type of pulse is often seen in patients with volume depletion or dehydration. An increase in pulse volume would be termed as a bounding pulse. When documenting in the patient record, all characteristics of the pulse should be noted, including rate, rhythm, and volume.
Taking an Apical Pulse ❖ Medications: Different medications can elevate or decrease pulse rates. ❖ Exercise or an increase in activity: Temporarily increases pulse rate. An excessively rapid heart rate, over 100 BPM, is referred to as tachycardia and may be a sign of fever, hemorrhage, dehydration, or heart disease. Vigorous exercise can cause the heart rate to exceed 200 BPM, which is why patients should be examined prior to the start of a strenuous exercise program to make certain that their hearts can handle the increased intensity. An abnormally slow heart rate, below 60 BPM, is referred to as bradycardia. Slow heart rate is often seen in athletes and during times of sleep. Pulse rhythm refers to the interval timing between measured beats. The intervals between each beat should be consistent and symmetric. Any irregularities are referred to as arrhythmias or dysrhythmias. Following speculation of an arrhythmia, a provider may order an electrocardiogram (EKG or ECG) to help determine the cause for the irregular rhythm. Refer to Chapter 15 for more information on EKGs. The pulse volume, or strength of the pulse, refers to the amount of blood being discharged from the heart. It should remain consistent and strong. If the amount of blood pumped from the heart to the body is diminished, the pulse will feel weak or thready. The pulse rate will usually increase to compensate for the lower volume, and would be referred to as rapid and
The common location for assessing pulse is in the radial artery; however, when a radial pulse is difficult to palpate, an apical pulse should be performed. An apical pulse is taken with the aid of a stethoscope. The diaphragm of the stethoscope is placed over the apex of the heart or the fifth intercostal space just to the left of the midclavicular line. Refer to Figure 11-8 for proper placement of the stethoscope when performing an apical pulse.
Apical-Radial Pulse and Pulse Deficit If a provider orders an apical-radial pulse, two health care workers will take the pulse simultaneously; one counting the radial pulse and the other counting the apical pulse. Subtracting the radial measurement from the apical measurement equals the pulse deficit. For example: If the radial pulse is 72 and the apical pulse is 91, then the pulse deficit is 19 (91 – 72 = 19). This
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C R I T I C A L T H I N K I NG CHALLENGE You are having great difficulty locating a patient’s radial pulse. You have attempted to count the pulse rate in both arms but you just can’t feel it. 1. What should you do?
BASIC VITAL SIGNS AND MEASUREMENTS
Mid-clavicular
1 2 3 4 5 5th Intercostal space Apex
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outer environment). Figure 11-9 illustrates what happens during the respiration process. The structure within the brain that controls respiration is the medulla oblongata. When carbon dioxide levels rise in the blood stream, the medulla oblongata is alerted, and it triggers the process of respiration. The diaphragm, through contractions, alters the pressure within the thoracic cavity in the chest, causing involuntary inspiration, or the process of “breathing in.” After breathing in, the pressure inside the lungs is now less than the atmospheric pressure. This causes expiration to occur, to balance or equalize the inside and outside pressure. While breathing is often a process done naturally and unconsciously, the body is also able to alter the rate, depth, and pattern voluntarily. Figure 11-10 illustrates the position of the diaphragm during inspiration and expiration.
Respiratory Rate
FIGURE 11-8 Location of the apex of the heart where an apical pulse is counted
measurement is an indication that the strength of the contractions may not be sufficient enough to force adequate blood to the extremities. A pulse deficit is common in patients with atrial fibrillation. When documenting the results, include both pulse rates and the deficit calculation. Procedure 11-7 provides more information and the rationale in performing an apical pulse assessment.
The rate of respiration is documented as the number of breaths per minute. Table 11-6 lists the average respiratory rates for different age groups. Note that average respiratory rates decrease with age. Procedure 11-6 details the steps involved in obtaining an accurate respiratory rate. To obtain an accurate respiratory rate, patients should be unaware that you are measuring their respiration. Remember, breathing can be involuntary or voluntary, and patients may inadvertently or purposefully alter their breathing if they are aware of your actions.
FIGURE 11-9 What occurs during internal and external respiration Nose–mouth
Respiration The respiratory system is responsible for the transfer of oxygen (O2) and carbon dioxide (CO2) within the body. Essential for life, oxygen is taken into the body and distributed by the circulatory system to be used by all cells. Respiration, or the act of breathing, begins with the process of inspiration or inhalation, bringing air or oxygen into the body. After traveling through the respiratory branches in the lungs, alveoli (microscopic air sacs) transfer the required oxygen to the capillaries. As the blood in the circulatory system distributes the necessary oxygen to the cells, it also transfers carbon dioxide out of the cells and back to the lungs to be removed from the body through expiration or exhalation (the exhaling of waste products to the
Air blown wn out
Air ssuck cked ed in Airways of respiratory tree (ventilation)
Al eoli Alveoli
O2
CO2 Blood in pulmonary capillaries
External respiration (gas exchange between air in alveoli and blood in pulmonary capillaries) Tissue cells Blood flow CO2 O2
Blood flow
Blood in systemic capillaries
Internal respiration (gas exchange between tissue cells and blood in systemic capillaries)
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❖ Age: Respirations typically decrease with age, but may increase if pulmonary disease is present. ❖ Infectious states: Associated fevers may cause an increase in respiratory rate.
Irregular Breathing Patterns Diaphragm
Lung
Heart
Diaphragm
FIGURE 11-10 The positioning of the diaphragm during inspiration (left) and expiration (right)
Factors That Affect Respiration Like temperature and pulse, there are several factors that affect respiration, including: ❖ Physical activity: Activity normally increases respiration. (Did the patient just climb three flights of stairs?) ❖ Emotional factors: Emotions such as fear, panic, or rage may temporarily increase respiration. ❖ Medications: Some medications can cause respiration to either increase or decrease. Respiratory stimulants such as bronchodilators and decongestants cause an increase in respiration, and depressants such as barbiturates and tranquilizers cause a decrease in respiration.
TABLE 11-6 Average Respiratory Values Measured in Breaths per Minute AGE
RATE
Newborn
30–60/min
12–24 months
20–40/min
8–15 years
15–25/min
16 years–adult
16–20/min
Patients often experience irregular breathing patterns during respiratory illness or following a life-threatening injury. Table 11-7 lists some of those patterns as well as their characteristics. Depth during inhalation must also be noted. Three terms used to document depth include: ❖ Shallow, meaning the chest rises minimally ❖ Normal ❖ Deep, meaning the chest rises excessively The depth of inspiration versus expiration will be further evaluated by the provider. A prolonged expiration might indicate obstructive lung disease. Any difficulty noted while breathing should be documented. The following terms may be used when describing the patient’s respiration: ❖ Dyspnea means difficult or labored breathing. ❖ Orthopnea refers to breathing easiest while in a sitting or standing position. ❖ A rapid respiration rate with normal or shallow respirations is referred to as tachypnea. ❖ Rapid and deep respirations are called hyperpnea or hyperventilation. ❖ Breathing abnormally slow is referred to as bradypnea. Beyond the basic vital screening, the provider will evaluate the quality of respirations, including any sounds made during respiration. Normally, breathing should be quiet and effortless. Table 11-8 lists some of the breath sounds a provider might observe. Some breath sounds may only be heard with a stethoscope. Others may be obvious during a medical assistant’s initial screening of the patient. If the medical assistant hears any unusual sounds coming from the patient’s lungs, the provider should be notified right away.
Blood Pressure A patient’s blood pressure measures the amount of force exerted on the arterial walls as the heart ventricles contract and relax. When documenting blood pressure, it is recorded as a fraction. The phase at which the cardiac ventricles contract (forcing blood from the ventricles into the pulmonary artery and aorta) is referred to as systole. Systole occurs when the greatest amount of force is applied to the arterial vessels and
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TABLE 11-7 Irregular Breathing Patterns (Rhythm) BREATHING PATTERN
CHARACTERISTICS
Cheyne-Stokes breathing
A condition in which the patient exhibits deep breathing followed by periods of apnea, normally observed during sleep. Conditions in which this breathing pattern may be observed include heart or lung disease, drug-induced respiratory depression, or brain injury. This pattern is commonly seen prior to death.
Ataxic breathing
Irregular and unpredictable periods of breathing with no specific pattern. This type of breathing may indicate brain damage.
Sighing
Audible exhaling during a long deep breath. While some sighing is normal, frequent and regular sighs should be noted.
TABLE 11-8 Breath Sounds and Possible Indications BREATH SOUND
CHARACTERISTICS
POSSIBLE INDICATIONS
Rales
Usually heard on inspiration intermittently Usually sounds wet Pitch may vary
Local inflammatory process CHF Pulmonary edema Pneumonia
Rhonchi
Usually heard on expiration, but may also be heard on inspiration Sound may resemble a “honk” or snore
This may indicate some narrowing in the bronchi, and secretions in the larger airways. At times, these can clear with coughing.
Wheezing
High pitched, almost musical sounds heard during inspiration and/or expiration Can be heard at the mouth and chest
Asthma, COPD, CHF If localized, there may be a partial obstruction, possibly a tumor or foreign body.
Stridor
Wheeze-like crowing, heard during inspiration Often louder in the neck region than in the chest
Partial obstruction of larynx or trachea Croup Usually an urgent medical situation
Pleural rub
Creaking sounds similar to crackles but confined to specific area and discrete Usually heard on inspiration and expiration
Inflammation of pleural membranes
is referred to as the systolic pressure when measuring blood pressure. The systolic pressure is recorded as the numerator (or top number) when documenting blood pressure. The phase when the cardiac ventricles relax is referred to as diastole. The pressure is clearly lower during this phase as the heart relaxes and is referred to as the diastolic pressure when measuring a blood pressure. The diastolic number is recorded as the denominator (or lower number) of the measure-
ment. The standard unit in which blood pressure is measured is milliliters of mercury (mm Hg); however, the unit does not have to be recorded when documenting blood pressures. The difference between the systolic and diastolic pressure is referred to as the pulse pressure. This can be calculated by subtracting the denominator from the numerator. The normal range for the pulse pressure is between 30 and 50.
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Variables That Can Affect Blood Pressure There are several variables that can affect blood pressure. Table 11-9 lists several of those factors, along with a description of how each affects blood pressure.
Equipment Requirements When measuring blood pressure, it is essential that all equipment used is in good working order and appropriately matched to the size of the patient. The stethoscope is used to listen to different sounds produced within the body, such as a pulsating artery. Figure 11-11 illustrates the different components of a stethoscope and includes the ear pieces, tubing, and chest piece. Component descriptions include:
1. Ear pieces: Should be cleaned with alcohol prior to use and should be positioned so that they point toward the ear canal. The small holes in the end of the ear pieces must transfer the Korotkoff sounds, those sounds heard during a blood pressure measurement. If the holes are pushed against the sides of the ears, hearing will be difficult, if not impossible. 2. Tubing: Can be either single- or double-tubing. Tubing transfers the sounds from the chest pieces to the ear pieces. In high-quality stethoscopes with double tubing, sounds may be easier to hear. There is a downside, however. When the tubes touch, extraneous rubbing or tapping sounds may be heard
TABLE 11-9 Variables That Influence Blood Pressure Readings FACTOR
DESCRIPTION
Physiologic changes due to aging
As the patient ages, blood pressure normally increases. Children generally have lower BPs than adults. Older adults may have higher blood pressures than younger adults due to a loss of arterial elasticity or occlusion in the arterial walls.
Emotional state
A patient who is anxious or excited may have elevated blood pressure. “White coat hypertension” is often related to anxiety associated with the physician or just being in the medical office.
Medications
Many medications will raise or lower blood pressure, which is why it is essential to obtain a complete listing of all medications the patient is taking including herbs, vitamins, and mineral supplements.
Gender and race
Women’s blood pressures fluctuate with life-span changes, puberty, and menopause. Race and heredity will affect blood pressure as well. African Americans tend to have higher blood pressure readings than other races.
Diet and other chemicals
Electrolytes in the diet, such as sodium, can have an impact on blood pressure over an extended period of time. Immediate changes may occur after smoking or drinking caffeinated products.
Exercise
During exercise, blood pressure will temporarily rise.
Positioning of patient
The normal position for taking blood pressure is sitting. If another position is used, such as standing or lying down, it must be noted in the patient record.
Diurnal variances or time of day
During periods of higher metabolism such as when eating or exercising, blood pressure will generally rise. Conversely, when metabolism is at its lowest during periods of sleep, blood pressure will decline.
Inappropriate equipment size
Cuff sizes must be appropriate for the size of the patient. Large adult cuffs should be used on larger patients and pediatric cuffs should be used on children or very small adults. Cuffs that are too small may cause falsely elevated readings, while cuffs that are too large may cause falsely low readings.
Pain or discomfort
Pain or discomfort from a full bladder or constipation may cause blood pressure to rise.
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Tubing
Bell
Ear Pieces Diaphragm
FIGURE 11-11 Different parts of the stethoscope
and mistaken for Korotkoff sounds, causing a false reading. Single-tube or double-tubing stethoscopes are adequate for measuring blood pressures. 3. Chest piece: This is the component in which sounds are transmitted. It may consist of a diaphragm, a bell, or both. The diaphragm is used for highpitched sounds such as bowel sounds, while the bell is used for low-pitched sounds. The chest piece can be rotated until clicked into place or until the desired side is open. With the stethoscope in the ears, tap gently on the chest piece to determine if the correct side is open. If you cannot hear the tapping, either the ear pieces or the chest piece are not being utilized correctly. The sphygmomanometer, similar to those shown in Figures 11-12 and 11-13, is the actual piece of equipment that measures the blood pressure. It consists of an inflatable bladder contained within a cuff, a scale or gauge that measures the pressure as well as a bulb that inflates and deflates the cuff. Each part of the sphygmomanometer is described below: 1. Bladder and cuff: Should be wrapped securely around the upper arm or thigh and secured with a Velcro fastener. The center or bladder of the cuff should be placed directly over the brachial artery if using the arm for the measurement. Most cuffs have an arrow that should be pointed directly over the artery being used. It is extremely important to use the appropriate cuff size to ensure an accurate measurement. If the cuff size is too small, a falsely elevated
FIGURE 11-12 An aneroid sphygmomanometer
Blood Pressure Cuff
Velcro Fastener
Control Valve
Bulb Electronic Gauge
FIGURE 11-13 A digital sphygmomanometer
pressure may occur. Conversely, if the cuff is too large, a falsely low pressure may occur. According to the American Association of Family Practitioners (AAFP), a standard-size adult cuff should not be used for any patient whose upper arm is larger than 33 cm in diameter (just over 13 inches). Instead, a large adult cuff should be used. A thigh cuff should be used in patients whose upper arm diameter is larger than 45 cm or 20.4 inches. Figure 11-14 displays different sized cuffs that are used to obtain a blood pressure. 2. Gauge for measurement: May be either an aneroid gauge or a digital readout. The aneroid type becomes more inaccurate with extended use, so gauges will
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organs of the body. The eyes, heart, brain, and kidneys may develop pathological changes due to hypertension. Classifications of adult blood pressure are detailed in Table 11-10. Both systolic and diastolic pressures need to be evaluated independently and together.
Korotkoff Sounds
FIGURE 11-14 The correct size of blood pressure cuff must be used to obtain an accurate reading. From left to right, this photo shows cuffs for pediatric, adult, large adult, and thigh.
need to be recalibrated on a regular basis by a certified technician. The aneroid gauge has a round scale or dial that is calibrated in millimeters, in increments of two. If calibrated correctly, the needle will register zero when the cuff is completely deflated. The cuff contains a section where the aneroid gauge can be attached. This will prevent accidental dropping of the gauge and allows the medical assistant to have a free hand. The millimeter markings are small; therefore, the gauge must be placed so it can be easily read. A digital readout manometer simply displays the reading on a small screen. 3. Bulb: This part inflates and deflates the bladder and cuff. It should be handled with the dominant hand, allowing the rotation of the control valve with only the thumb and forefinger. This leaves the remainder of the fingers available to compress the bulb to inflate the bladder.
Correctly hearing and interpreting the sounds during the measurement of a blood pressure involves listening for the different sounds as blood begins to flow back into the brachial artery. Initially, a faint pulsing sound is heard, which gradually increases in intensity. The first sound that is heard is registered as the systolic pressure. This is phase one of the Korotkoff sounds. As the sound intensifies, it takes on a swooshing tone, which is phase two. As pressure is slowly and steadily released from the bladder, the sounds become stronger, signaling phase three. During phase four, the pulsation sounds become softer and more muffled. This distinct change is the diastolic pressure in children. Phase five is when the sounds are totally inaudible, which is the diastolic pressure in adults. The difference between phase four and phase five should normally be only a few mm Hg. If the difference between phase four and five is greater than 10 mm Hg, then record all three measurements: the systolic, phase four, and phase five (for example, 162/94/68). It is important to note that occasionally the Korotkoff sounds never disappear. Refer to Procedure 11-8 for a complete list of steps necessary to obtain an accurate blood pressure reading.
Pain Assessment The assessment of pain is now being considered as the fifth vital sign. It is often difficult for patients to rate TABLE 11-10 Classifications of Adult Blood Pressure
Blood Pressure Classifications It is important to routinely monitor blood pressures since hypertension (high blood pressure) affects many
TOOL BOX
F IEL D S M A R T S Terms associated with low blood pressure include hypotension (low blood pressure) and orthostatic hypotension (blood pressure that drops upon standing).
CLASSIFICATION
SYSTOLIC (mm Hg)
DIASTOLIC (mm Hg)
Normal or ideal
Less than 120
Less than 80
Prehypertensive
120–139
80–89
Stage 1 hypertension
140–159
90–99
Stage 2 hypertension
Greater than 159
Greater than 99
Source: Seventh Report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7).
F IELD SM A RTS Auscultatory gap is an occurrence in which Korotkoff sounds diminish and become inaudible (a period of silence) during phase two or phase three of the blood pressure measurement. The sounds later reappear as the blood pressure cuff is deflated. Ausculatory gap is most com-
mon in patients with hypertension and in older patients. To make certain that you obtain the correct systolic pressure, try performing blood pressure using the palpatory method. Lifting the arm in the air prior to inflation of the cuff may also help to eliminate this occurrence.
TOOL BOX
TOOL BOX
E M R A P P L I C AT I O N
C R I T I C A L T H I N K I NG CHALLENGE
Vitals can easily be entered into the EMR by clicking on the vital signs tab and entering the appropriate data. Many software programs are able to graph vitals over a specific period of time. You merely list what dates are to be graphed and the electronic software does the rest.
or describe their pain. The medical assistant should provide a measuring tool that will turn a patient’s subjective description into a more objective measurable field. One tool that may be to used to measure pain is a number scale. Ask the patient to rate the pain using the numbers 1 to 10 (1 represents very mild pain and 10 represents the worst pain ever experienced). Continuous monitoring of pain during each office visit will show trends in pain and may have a bearing on treatment plans. Another tool that can be used to describe pain is the use of pictures of faces illustrating different emotions. This type of tool is commonly used when working with pediatric patients or patients with language barriers. Refer to Chapter 6 for further explanation on assessment of pain and assessing patient needs.
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When performing a blood pressure on Mr. Timmons, you obtained a reading of 164/110. Dr. Wong retook the blood pressure and obtained a reading of 190/110. You are frustrated because you pumped the cuff up to 180 but didn’t hear anything until 164. 1. What may be the reason for the discrepancy?
Pulse Oximetry The measurement of pulse oximetry indicates the amount of arterial oxygen (O2) saturation in the blood. An external probe is attached to an area that has good blood perfusion, such as the earlobe, lip, fingertip, or toe. Depending on the equipment used, the oximeter may calculate oxygen saturation and pulse rate simultaneously. An oxygen saturation of less than 95% implies that oxygen saturation is not adequate and that intervention is necessary. Refer to Chapter 16 to learn more about pulse oximetry.
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PROCEDURE 11-1 Obtain the Height and Weight of an Adult Patient Objective: To accurately obtain and document an adult’s height and weight.
Equipment/Supplies: ❖ Upright scale ❖ Paper towel
❖ Patient record
PROCEDURAL STEPS
RATIONALE
1. Place the scale weights at zero.
Move all of the weights to the left of the scale.
2. Check that the scale is balanced and adjust, if necessary (Figure 11-15).
A calibrated scale is necessary for an accurate measurement.
FIGURE 11-15 Balance bar of scale frequently used in providers’ offices 3. Wash your hands.
Handwashing is the principal method of preventing the spread of infection.
4. Identify the patient using two identifiers, identify yourself, and explain the procedure.
Identifying the patient ensures that the procedure and examination are performed on the correct patient. Explaining the procedure increases compliance and patient comfort.
5. Assess the stability of the patient.
This will determine how much assistance the patient may require.
6. Have the patient remove any unnecessary clothing, such as a jacket or sweater, as well as shoes.
Clothing will alter the patient’s weight.
7. Place a paper towel on the floor of the scale.
A clean towel will help prevent cross-contamination between patients.
8. Assist the patient onto the scale, facing the weights. 9. Instruct the patient to stand on the center of the scale and to hold still (Figure 11-16). Slowly adjust the weights until the scale arrow is balanced. 10. Record the measurement.
Motion can alter the results of the weight. Remind the patient to remain still during the measurement.
BASIC VITAL SIGNS AND MEASUREMENTS
FIGURE 11-17 The height FIGURE 11-16 The patient should stand still in the middle of the scale while the medical assistant balances the bar to obtain an accurate weight.
bar should be raised high enough for the patient to step on the scale without the bar touching the patient’s head.
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FIGURE 11-18 Adjust the height bar so it rests on the top of the patient’s head. Be sure to push the hair down so the bar is resting on the head itself and not the hair.
RATIONALE
11. Return the weights to zero.
The scale must be balanced to obtain an accurate measurement.
12. Assist the patient off the scale.
Slips and falls may occur when moving off any equipment. Providing assistance will reduce the chance for a mishap.
13. Raise the calibrated height bar to a height that would be greater than the patient’s height (Figure 11-17).
This is performed with the patient off the scale to avoid striking the patient in the head with the height bar.
14. Extend the bar used to measure to a horizontal position. 15. Assist the patient back onto the scale platform, back toward the measurement tool. Have the patient stand as erect as possible (Figure 11-18). 16. Lower the horizontal bar slowly and gently until it reaches the top of the patient’s head, forming a 90° angle with the height bar.
Continue to hold onto the height bar while the patient steps off the scale to prevent the bar from falling and possibly hitting the patient in the head.
17. Assist the patient off the platform.
This ensures patient safety.
18. Record the measurement.
Read the height at the moveable point of the ruler. The markings are measured in 1⁄4 inch increments.
19. Place the measurement bar back to its original position. 20. Discard the paper towel. 21. Document the results in the patient record (if you didn’t already). Convert weight into kilograms if necessary.
The kilogram measurement may be used in some medication calculations.
DOCUMENTATION EXAMPLE:
12-05-XX 9:35 a.m.
Wt. 135# Ht. 4'11", shoes removed. Carla Carlyle, CMA (AAMA)
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PROCEDURE 11-2 Obtain an Oral Body Temperature Objective: To obtain and document an accurate oral body temperature reading.
Equipment/Supplies: ❖ Electronic thermometer ❖ Probe covers
❖ Patient record
PROCEDURAL STEPS
RATIONALE
1. Wash your hands. (Gloving is optional.)
Handwashing is the principal method of preventing the spread of infection.
2. Assemble the equipment.
Having all the necessary supplies ready before obtaining the temperature saves time.
3. Identify the patient using two identifiers, identify yourself, and explain the procedure.
Identifying the patient ensures that the procedure and examination are performed on the correct patient. Explaining the procedure increases compliance and patient comfort.
4. Ask if the patient has ingested hot or cold food or beverages or smoked within the last half hour.
Ingesting hot or cold liquids or foods and smoking can adversely affect the temperature reading making it inaccurate. (Either allow patient to wait or select another method if any of the variables apply.)
5. Select the blue oral probe and cover it with a disposable probe cover (Figure 11-19).
It is important to select the correct probe because different probes are intended for particular sites.
6. Place the thermometer in the patient’s mouth under the tongue to the right or left side of the frenulum linguae (Figure 11-20).
This area of the mouth is highly vascular and gives a more accurate temperature reading.
7. Instruct to patient not to clench or bite down on the thermometer and to hold the mouth closed and breathe through the nostrils, not through the mouth.
Clenching or biting down on the thermometer may cause improper placement of the thermometer and result in an inaccurate reading.
8. Keep the thermometer in place until a tone or beep is heard.
The beep indicates that the thermometer is ready to be read.
FIGURE 11-19 Place a clean disposable probe cover on the probe of the electronic thermometer before inserting it into the patient’s mouth.
FIGURE 11-20 Place the thermometer under the patient’s tongue and to the side.
BASIC VITAL SIGNS AND MEASUREMENTS
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9. Remove the thermometer and read the digital display (Figure 11-21).
FIGURE 11-21 Easy-to-see digital readout of the temperature reading 10. Discard the used probe cover following institutional guidelines (Figure 11-22).
This prevents crosscontamination from one patient to the next.
11. Place the electronic thermometer base back in the base holder for recharging.
If the thermometer is not recharged, the battery will die.
12. Wash your hands and record the temperature reading in the patient record.
DOCUMENTATION EXAMPLE:
04-27-XX 3:30 p.m.
T 99.9°F. Lilly Kelly, CMA (AAMA)
FIGURE 11-22 Dispose of the used probe cover following institutional policy.
PROCEDURE 11-3 Obtain an Aural Body Temperature Objective: To obtain an accurate aural temperature reading using a tympanic thermometer.
Equipment/Supplies: ❖ Tympanic thermometer ❖ Disposable probe covers
❖ Waste container ❖ Patient record
PROCEDURAL STEPS
RATIONALE
1. Wash your hands. (Gloving is optional.)
Handwashing is the principal method of preventing the spread of infection.
2. Assemble the equipment. Ensure that the thermometer is charged, clean, and in working order.
Review the equipment manual on proper cleaning procedures. continues
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RATIONALE
PROCEDURAL STEPS 3. Identify the patient using two identifiers, identify yourself, and explain the procedure.
Identifying the patient ensures that the procedure and examination are performed on the correct patient. Explaining the procedure increases compliance and patient comfort.
4. Place a clean probe cover over the tympanic probe (Figure 11-23) and make certain the unit is turned on and in the “ready” mode.
A clean probe cover prevents cross-contamination between patients.
5. Straighten the aural canal to best facilitate an accurate measurement (Figure 11-24). (Pull the auricle up and back on adults and children over the age of three. Pull down and back on anyone younger than age three).
The tympanic thermometer relies on obtaining the measurement by having a direct pathway to the tympanic membrane. Thermal energy is radiated by the tympanic membrane.
6. Place the covered probe into the patient’s ear canal (Figure 11-25), forming a tight seal and pointing the probe toward the eardrum.
The probe must be sealed in the ear canal for the most accurate results. If cool air is allowed to travel into the ear canal, the temperature will register cooler, creating a false reading.
7. Activate the thermometer while having the patient quietly relax.
Pressing the button on the top of the thermometer handle will activate the thermometer.
8. Leave the probe in place until the unit beeps. The temperature will be displayed digitally on the thermometer. 9. Discard the probe cover in the appropriate waste container. Return the thermometer to storage. 10. Wash your hands. 11. Document the results, including which ear was used for the measurement.
DOCUMENTATION EXAMPLE:
11-04-XX 3:00 p.m.
T 99.2°F, TM, L. ear. Cassy Smith, RMA
FIGURE 11-23 Place a disposable probe cover on the tympanic thermometer probe to prevent cross-contamination.
FIGURE 11-24 The ear canal should be straightened to facilitate easy insertion of the thermometer and to obtain an accurate reading.
FIGURE 11-25 Gently insert the probe into the patient’s ear canal.
BASIC VITAL SIGNS AND MEASUREMENTS
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PROCEDURE 11-4 Obtain an Axillary Body Temperature Objective: To obtain an axillary temperature reading using an electronic or digital thermometer.
Equipment/Supplies: ❖ Electronic thermometer ❖ Disposable probe covers
❖ Patient record
PROCEDURAL STEPS
RATIONALE
1. Wash hands. (Gloving is optional.)
Handwashing is the principal method of preventing the spread of infection.
2. Assemble the equipment. Ensure that the thermometer is clean and in working order.
Some digital thermometers can have the reading mode changed to axillary mode and register the actual body temperature plus one degree for temperature variances between sites.
3. Identify the patient using two identifiers, identify yourself, and explain the procedure.
Identifying the patient ensures that the procedure and examination are performed on the correct patient. Explaining the procedure increases compliance and patient comfort.
4. Place a clean sheath or probe cover over the oral probe.
Using a clean probe cover prevents cross-contamination. For axillary temperatures, the oral (blue) probe is used.
5. Have the patient remove clothing that interferes with the axillary region. Offer a gown or drape for coverage.
The thermometer must be placed against the skin, not through the clothing to obtain an accurate reading.
6. Pat the armpit with a dry paper towel if perspiration is present (or have the patient do it).
Perspiration could cause an inaccurate reading.
7. Place the probe tight in the center of the axilla (Figure 11-26). 8. Instruct or assist the patient in holding the arm tight against the body, holding the thermometer in place.
It must fit snuggly in the armpit; air currents will cause an incorrect reading.
9. Keep the thermometer in place until the digital device emits a tone, indicating completion of the reading.
The timing of the reading is determined by the digital unit itself.
10. Note the temperature reading. 11. Discard the probe cover in the appropriate container.
FIGURE 11-26 The patient holds his arm This is done by pressing the close to his body as the release button on the end of medical assistant takes the probe. It will be ejected his axillary temperature. into the trash receptacle without you having to touch the sheath. (If using a standard glass thermometer, remove the plastic sheath and discard it in the appropriate container.) continues
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PROCEDURAL STEPS 12. Replace the probe into the digital unit and replace the unit in the charging base.
RATIONALE Charging should occur when not in use. If a unit is not properly charged, the battery will die.
13. Wash your hands. 14. Assist the patient with clothing if needed. 15. Document the results.
DOCUMENTATION EXAMPLE:
8-7-XX 2:35 p.m.
T 97.4°F Axillary. Lori Moore, CMA (AAMA)
PROCEDURE 11-5 Obtain a Temporal Artery Body Temperature Objective: To obtain an accurate body temperature reading using a temporal artery thermometer.
Equipment/Supplies: ❖ Temporal artery themometer ❖ Alcohol wipes
❖ Patient record
PROCEDURAL STEPS
RATIONALE
1. Wash your hands.
Handwashing is the principal method of preventing the spread of infection.
2. Assemble the equipment. Clean the thermometer probe with an alcohol swab and ensure that it is working properly.
Keeping the measuring probe clean will help the thermometer to produce accurate readings.
3. Identify the patient using two identifiers, identify yourself, and explain the procedure.
Identifying the patient ensures that the reading is being performed on the correct patient. Explaining the procedure increases compliance and patient comfort.
4. Remove hats or scarves on the side of the head that is to be measured and pull hair back if applicable.
The area to be measured must be exposed to the environment. Hats, scarves, and hair can hold heat in, resulting in an inaccurate reading.
5. Check the forehead for perspiration. Wipe dry if perspiration is present.
Perspiration can interfere with an accurate reading.
BASIC VITAL SIGNS AND MEASUREMENTS
PROCEDURAL STEPS
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RATIONALE
6. Depress the scan button and begin by placing the probe at the midline of the forehead. Keep probe flush with the skin and slowly glide the thermometer across the forehead until the probe reaches the hairline on the side of the head over the temporal artery (Figures 11-27 and 11-28).
Holding the probe flush with the skin will ensure an accurate reading.
7. When the reading is complete, release the scan button, lift the probe from the patient’s skin, and check the display for the reading. (Take a second reading behind the ear under the mastoid process if necessary.)
Once the scan button is released, the reading will remain in the display window for a short period of time.
8. Clean the probe and accurately document the reading and the method by which the reading was obtained in the patient record.
The method must always be recorded. Otherwise, the method will be assumed to be oral.
FIGURE 11-27 The temporal thermometer probe is placed flush with the skin at the midline of the forehead.
DOCUMENTATION EXAMPLE:
10-10-XX 10:30 a.m.
T 98.6°F (TA). Kelly Leonard, CMA (AAMA) FIGURE 11-28 The medical assistant slides the probe across the forehead and ends with the probe over the temporal artery.
PROCEDURE 11-6 Obtain a Radial Pulse Rate and Respiration Rate Objective: To obtain an accurate pulse and respiration rate.
Equipment/Supplies: ❖ Watch with a second hand
❖ Patient record
PROCEDURAL STEPS
RATIONALE
1. Wash your hands.
Handwashing is the principal method of preventing the spread of infection.
2. Identify the patient using two identifiers, identify yourself, and explain the procedure.
Identifying the patient ensures that the procedure and examination are performed on the correct patient. Explaining the procedure increases compliance and patient comfort.
3. Place the patient in a calm, quiet environment. Allow the patient to relax in a sitting position with the arm in a comfortable location.
Anxiety can alter pulse and respiratory measurements. The patient should be calm and quiet. continues
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PROCEDURAL STEPS 4. Locate the radial pulse with your index and middle fingers. The hand you use should be opposite from the hand on which you wear your watch. Never use your thumb when measuring the pulse (Figure 11-29).
RATIONALE The tips of the fingers are very sensitive and able to palpate the pulse easily. The thumb has its own pulse. If you use a thumb for measurement, you may be feeling your own pulse rather than the pulse of the patient.
FIGURE 11-29 If the radial pulse is regular, count for 30 seconds and multiply by two.
5. Apply slight pressure onto the radial artery. Increase pressure until the pulse is felt.
Too much pressure will close off the artery so that the pulse cannot be felt. (The amount of pressure will be learned with experience.)
6. Count the number of beats for a minimum of 30 seconds. Multiply this number by two for a full-minute rate.
Fewer than 30 seconds may cause you to miss abnormalities. Pulse and respirations are recorded as beats or breaths per minute so you will need to multiply your reading by two when performing a 30-second check.
7. Note if there are any irregular beats that occur.
If there are any irregular beats noted, count the pulse rate for a full minute.
8. Maintain fingers on the pulse and begin counting respirations.
The patient will perceive that you are still measuring pulse. Respirations can be altered by the patient; therefore, it is best if the patient is not aware the measurement is being obtained.
9. Count the number of breaths for 30 seconds. Multiply this number by two for a full-minute rate. 10. Note any irregular breath sounds.
Extra motions, such as flaring nostrils or pursing lips, as well as other sounds may indicate respiratory disorders. They must be communicated to the provider.
11. Wash your hands. 12. Document the results of the pulse and respirations in the patient record.
DOCUMENTATION EXAMPLE:
10-4-XX 9:30 a.m.
P 84 and reg; R 16, unlabored, and reg. Mattie Jones, CMA (AAMA)
BASIC VITAL SIGNS AND MEASUREMENTS
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PROCEDURE 11-7 Obtain an Apical Pulse Rate Objective: To obtain an accurate apical pulse reading.
Equipment/Supplies: ❖ Stethoscope ❖ Watch with second hand
❖ Patient record
PROCEDURAL STEPS
RATIONALE
1. Wash your hands.
Handwashing is the principal method of preventing the spread of infection.
2. Assemble the equipment. Sanitize the stethoscope.
Keeping the stethoscope clean will help reduce risk of cross-contamination.
3. Identify the patient using two identifiers, identify yourself, and explain the procedure.
Identifying the patient ensures that the procedure and examination are performed on the correct patient. Explaining the procedure increases compliance and patient comfort.
4. Instruct the patient to expose the chest area by either unbuttoning the shirt or removing clothes from the waist up. Provide a gown for privacy.
There must be access to the chest region for auscultation of the apical pulse.
5. Remove clothing, gown, or drape covering the left thoracic area.
Attempting to measure the pulse through clothing can cause extraneous noises that may alter the assessment.
6. Place the stethoscope in your ears correctly.
The ear pieces must be pointed in the direction of the ear canal.
7. Locate the apical pulse.
The apical pulse is located at the fifth intercostal space, at the left midclavicular line.
8. After warming the diaphragm of the stethoscope, place it over the apex of the heart (Figure 11-30).
Cold stethoscopes are uncomfortable for the patient. The apex provides the best sound for counting the respirations.
9. Count the beats for one full minute. 10. Note any irregularities, along with the quality of sound.
Unusual sounds and patterns of the heartbeat may indicate pathology. This must be communicated to the provider.
FIGURE 11-30 The apical pulse can be counted by placing the stethoscope over the apex of the heart.
11. Remove the stethoscope. 12. Assist the patient in redressing or draping. 13. Wash your hands. 14. Record the results in the patient record.
DOCUMENTATION EXAMPLE:
4-6-XX 7:45 a.m.
P 86 (ap) and irreg. Cindy Brown, RMA
Be aware if there is another examination to follow to prevent the patient from having to undress again.
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PROCEDURE 11-8 Obtain a Blood Pressure Measurement Using the Palpatory Method Objective: To accurately obtain a blood pressure reading.
Equipment/Supplies: ❖ Sphygmomanometer with appropriate cuff size ❖ Stethoscope PROCEDURAL STEPS
❖ Alcohol wipes ❖ Patient record RATIONALE
1. Wash your hands.
Handwashing is the principal method of preventing the spread of infection.
2. Assemble the equipment. Sanitize the stethoscope (Figure 11-31).
Keeping the stethoscope clean will help reduce risk of cross-contamination.
3. Test the equipment to make sure the bulb and gauge are in working order. Tighten the bulb valve and inflate the cuff briefly.
The cuff should inflate properly and hold air without leakage. The gauge should be at zero when the cuff is not inflated and should remain in position according to the pressure of the cuff.
4. Remove any air from the cuff bladder.
This ensures a more accurate reading.
5. Identify the patient using two identifiers, identify yourself, and explain the procedure.
Identifying the patient ensures that the procedure and examination are performed on the correct patient. Explaining the procedure increases compliance and reduces patient anxiety.
6. Assess the patient’s upper arm diameter to determine if the size of the cuff selected is adequate.
An incorrect cuff size will produce inaccurate results.
7. Position the patient in a quiet, comfortable position.
The patient should be calm for the best results. Blood pressure can be falsely elevated with increased anxiety or stress.
8. Roll up the patient’s sleeve or remove any clothing or garments from the arm that will be used for obtaining the blood pressure.
Tight clothing will hinder the blood flow to the brachial artery.
9. Palpate the brachial artery for a viable pulse (Figure 11-32).
Make a mental note of the location of the strongest pulse.
FIGURE 11-31 The ear pieces and chest piece of the stethoscope should be cleaned with alcohol before use.
FIGURE 11-32 Palpate the brachial artery for a viable pulse.
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10. With the patient’s palm facing upward, wrap the cuff around the upper arm 1 to 2 inches above the bend of the elbow. The cuff should be snug but not overly tight. The arrow on the cuff, R for right arm and L for left arm, should align with the artery (Figure 11-33). Position the arm so that it is at heart level.
If the cuff is not snug, it could cause an inaccurate reading. If the artery is above the level of the heart, a false low reading might be registered.
11. Adjust the stethoscope so that the sound is coming from the side of the chest piece being used. Lightly tapping on the bell or diaphragm with the ear pieces in place will confirm correct side.
The bell works best for blood pressure sounds. If only a diaphragm is available, it can be used.
12. Adjust the manometer so it is clipped to the cuff and is in clear view.
Clear vision is important for accurate readings. The markings are small so they must be within a readable distance.
13. Hold the bulb in the palm of your dominant hand with the valve between the thumb and first finger. Turn the valve clockwise until closed.
Tighten the valve only until it is closed. Over tightening will damage the valve, and difficulty releasing the valve can cause interruption in the procedure.
14. With the other hand, locate the radial pulse. 15. Using the bulb, squeeze and inflate the cuff while palpating the radial pulse. Continue until the pulse is no longer felt. Proceed with inflation until the cuff has been inflated 30 mm Hg beyond pulse cessation.
As the cuff inflates, the blood flow to the radial artery subsides. The pulse can no longer be felt.
16. Slowly open the valve to release air from the cuff while palpating the radial pulse. Release at 2–3 mm Hg per second. Note the pressure on the manometer when the pulse returns.
The reading where the pulse returns is an estimate of the patient's systolic pressure. If the patient already has an office baseline, the palpated BP may not need to be done.
17. Open the valve completely and remove all air from the cuff. 18. After waiting 30 seconds, prepare to take the blood pressure. 19. Place the stethoscope correctly in your ear canals. Place the chest piece over the brachial artery (Figure 11-34). Hold the stethoscope in place with the first two fingers of your hand. Do not hold with your thumb over the chest piece as you may pick up your own pulse. Avoid touching the cuff with the stethoscope. Avoid having the tubing of the stethoscope come in contact with anything.
The thumb pulse may be heard through the diaphragm, confusing the measurement. Any additional sounds will cause confusion. Touching the tubing to anything will create extraneous sounds.
continues
FIGURE 11-33 The blood pressure cuff should be placed so that the arrow lines up with the artery.
FIGURE 11-34 Placing the stethoscope directly over the brachial artery makes the blood pressure easier to hear.
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PROCEDURAL STEPS
RATIONALE
20. Tighten the valve by turning it clockwise and pump the cuff rapidly up to 20 mm Hg above the palpated systolic pressure.
Pumping the cuff 20 mm Hg beyond the palpated systolic pressure will keep you out of the ausculatory gap.
21. Begin to release the pressure in the cuff by slowly turning the valve counterclockwise, 2–3 mm Hg per second. Observe the manometer carefully. Note the measurement when the first beat is heard. This is the systolic pressure.
The systolic pressure occurs when the blood begins flowing into the brachial artery.
22. Continue to deflate the cuff at this speed. Observe the manometer carefully and note the measurement when the sound ceases. This is the diastolic pressure. 23. Open the valve completely to deflate the cuff quickly and remove all air from the cuff.
Remove the air quickly after the reading has been made to reduce discomfort for the patient.
24. Remove the stethoscope and cuff. 25. Wash your hands. 26. Record the results in the patient record.
DOCUMENTATION EXAMPLE:
3-2-XX 4:30 p.m.
BP 142/82 L. arm.Tim Hall, CMA (AAMA)
Chapter Summary Vital signs are important indicators of the patient’s health. Accuracy in taking and documenting vital signs is imperative to make certain that provider is able to diagnose the patient properly and the patient obtains the proper care. Baseline readings are normally taken during the patient’s first appointment and evaluated each time the patient returns to the office. Medical assisting students should practice vital signs throughout the entire program. Externship sites will be less forgiving of students who struggle in performing vital sign procedures, more than any other procedures performed.
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FIELD APPLICATION CHALLENGE You are working in a family practice office and a regular patient, Mrs. Collins, age 72, walks in complaining of feeling dizzy with a headache. You have assisted with her examinations many times in the past. She appears flushed and irritated. On the way to the examination room, she stumbles slightly. Because she seems weak, you decide not to weigh her and to take her vitals in the exam room. Her blood pressure is elevated. She seems confused when you ask her about her medications. She was on an antihypertensive medication at the time of her last visit. She took a cab to the clinic for her appointment because she was afraid to drive. No
relatives are with her, although her daughter usually accompanies her. 1. What method of obtaining temperature would you suggest? 2. How much of an elevation in the blood pressure would be a cause for concern? 3. What information is of foremost importance to the provider? 4. Would you leave her unaccompanied in the exam room?
Chapter Assessment 1. During the initial screening of the patient, the medical assistant observes: a. appearance. b. gait. c. odor. d. emotions. e. all of the above. f. b and c only. 2. Causes of heat production include all of the following except: a. exercise. b. shivering. c. perspiration. d. diet. 3. Which of the following pulse rates would be considered as normal for an adult? a. 120 BPM b. 40 BPM c. 102 BPM d. 68 BPM 4. The average respiratory rate for an adult is: a. 12–14 per minute. b. 42–44 per minute. c. 16–20 per minute. d. 24–28 per minute.
5. The respiratory rate can be affected by all except: a. physical activity. b. emotions. c. medications. b. diet. 6. The pulse pressure when taking a blood pressure indicates the: a. difference between the palpable systolic and diastolic pressures. b. difference between the palpable systolic and auditory systolic pressures. c. difference between the palpable diastolic and auditory diastolic pressures. d. difference between the auditory systolic and diastolic pressures. 7. When taking an apical pulse, the stethoscope chest piece is placed in what location? a. Between the third and fourth ribs b. Over the apex of the heart in the fifth intercostal space c. At the midaxillary line of the fifth intercostals space d. At the midnipple line between the third and forth ribs
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8. If the medical assistant notices that there is an irregularity when taking a pulse, the pulse should be taken for what additional length of time? a. 15 seconds b. 30 seconds c. 1 minute d. 2 minutes
Web Activities 1. Visit the American Heart Association Web site for current guidelines on hypertension screening. 2. Look at medical distributors online for home use equipment that might be available for patients.
3. Do research to determine if a wrist BP cuff is as accurate as an arm or thigh cuff. What other methods for determining BP are available?
CONNECTION Using your StudyWARE CD-ROM: ❖ Complete the Concentration and Crossword activities for this chapter. ❖ Complete the Quiz for this chapter in Test Mode.
C H A P T E R
The Physical Exam
Essential Terms
Chapter Outline The Examination Room Preparation of the Exam Room Instruments for Examination Patient Preparation
12
Patient Positioning and Draping Patient Assessment Completing the Visit
Developmental Objectives After completing this chapter, you should be able to: 1. Correctly spell and define essential terms. 2. Name and discuss the indications for equipment and instruments used by the health team in physical examinations. 3. List and define the four techniques used during the physical examination. 4. Explain the room maintenance and cleaning procedures that are performed by the medical assistant. 5. Explain the various patient positions utilized during the physical examination, including the indications for each. 6. Explain the technique and purpose of draping the patient in each position. 7. List the responsibilities of the medical assistant when assisting the provider with a patient examination. 8. List the medical assistant’s responsibilities in completing a patient visit.
auscultation examination inspection manipulation mensuration observation palpation percussion posture tympany vertigo
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KEY COMPETENCIES
CAAHEP
ABHES
Preparation of the Examination Room
III.C.3.b.1.d III.C.3.b.1.e
VI.A.1.a.4.g
Positioning and Draping a Patient
III.C.3.b.4.e
VI.A.1.a.4.b
Assisting with the General Physical Examination
III.C.3.b.4.e
VI.A.1.a.4.h
Introduction The physical examination is a process during which the body is inspected and its systems are evaluated to determine the presence or absence of disease. The medical assistant’s role in assisting with the physical exam is multifold and varied in different situations. Preparation of the office environment for the examination often occurs before any patient involvement. Anticipating the needs of both the evaluator (provider) and the patient allows for a professional, efficient, and thorough office visit or procedure. Responding to provider and patient requests is only a small portion of the medical assistant’s responsibility. Becoming a professional involves assessing a situation and anticipating solutions. Assisting with the examination involves all of the senses, and especially includes active listening. The medical assistant provides information to other health providers regarding the patient, serving as a liaison between the patient and the provider. The medical assistant is often the interpreter or reinforcer of important medical information directed toward the patient. The medical assistant’s professional role in the physical examination involves being an environmental aide, a compassionate assistant, an informed instructor, an empathetic listener, and a liaison.
THE EXAMINATION ROOM Preparing the exam room for patient examination and procedures is often the responsibility of the medical assistant. This includes maintaining a clean and prepared examination room. Room temperature must be conducive to examinations. Efficiency of the exam is increased when all instruments and supplies are readily available.
Preparation of the Exam Room With the continuous flow of patients during a normal office day, the medical assistant must be thorough and efficient in preparing the examination room for
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FI E L D S M A R T S Remember that the patient is often stressed during an examination. Stress may cause the patient to forget what has been communicated. You should listen carefully to all instructions from the provider in order to “remind” and “reeducate” the patient if needed to ensure better patient compliancy after care.
THE PHYSICAL EXAM
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F IEL D S M A R T S As each patient exits the office, immediately clean and prepare the room for the next patient. This promotes a smoother patient flow. Waiting until the next patient arrives to prepare the room often results in delays.
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❖ Prepare any items necessary for the next patient (adjustments or supply enhancement may be made following the patient interview). Cleanliness is important to the health and safety of the patient, the provider, and all allied health personnel. Figure 12-1 shows two exams rooms. In which one would you rather be a patient? For detailed instructions and rationale on preparing the exam room, refer to Procedure 12-1.
Instruments for Examination
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F IEL D S M A R T S Envision yourself as the patient. Remember that the patient may not be feeling well. Smells, sounds, and lighting might cause unnecessary distress. Any time—whether it is in class, lab, or during an externship—that you can put yourself in the patient’s shoes you will gain a better understanding of how every action you perform, including preparing the examination room, can affect the patient’s perception and health.
All examinations require some type of tools or instruments. A professional familiarizes herself with the different types of instruments and equipment used in each office setting. Equipment and instrument selection will vary with each type of medical practice and each type of procedure or exam. For example, an orthopedic FIGURE 12-1a An example of an exam room that is not ready for a new patient. There is evidence of the former patient and the room is unclean and unorganized.
each patient’s needs. Following the dismissal of each patient, the medical assistant should promptly prepare the examination room for the next patient. The medical assistant should put on the appropriate PPE before cleaning the exam room for protection from items that contain infectious body fluids. Guidelines for preparing the exam room include the following: ❖ Discard all disposable items such as used drapes, gowns, bandaging material, wrappers, and other such items into the proper trash receptacles. ❖ Place nondisposable gowns and drapes in the laundry bin. ❖ Place all reusable items in the proper storage area. ❖ Place the exam table in its proper position and properly arrange all furniture. ❖ Thoroughly disinfect all counter surfaces and the exam table with an approved disinfectant. ❖ If the flooring needs tending, clean according to office policy. ❖ Restock supplies that are running low. ❖ Spray deodorizer if lingering odors are present. Spray disinfecting spray if the previous patient had a communicable disease.
FIGURE 12-1b An example of a clean and well-organized exam room that is fresh and ready for the next patient.
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PAT I E N T P E R S P E C T I V E Patient A: “I have never been to this office. Boy, this room looks and smells clean. It’s even comfortable and warm. This must be a really good practice.”
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S I T E C H EC K Patient safety is very important. As a site reviewer, I will check to make certain that the office institutes measures to promote patient safety. It is important to take a few moments to periodically sit in the reception room chairs or on the exam table and look for potential dangers—such as frayed electrical cords or sharps containers that are accessible to a curious child. Remember, patients and family members may spend brief periods of time alone in the exam room. Being proactive creates a professional and peaceful environment; being reactive promotes havoc and chaos.
Patient B: “It sure looks like another person was sitting on this exam table, and it kind of smells. I wonder if this gown is clean! I will never come back to this practice.”
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turer. Table 12-1 describes the various types of equipment used in a standard medical examination. The medical assistant should have a basic understanding of the function of each piece of equipment or instrument prior to the exam. Some equipment is used only rarely. Periodic review of this equipment is essential for the medical assistant to remain proficient in its use and upkeep. Assurance that equipment is functional, including the replacement of batteries, is often delegated to the medical assistant. In addition to the routine physical exam, other procedures are often performed in the office, usually requiring additional equipment or instruments. Chapter 22 discusses proper identification and maintenance of surgical instruments that are utilized during minor office surgical procedures.
PATIENT PREPARATION office will use a different selection of instruments than an OB-GYN office. Some tools, though, are standard within all practices. Figure 12-2 illustrates the different instruments that are used for a physical exam. In reality, these may vary slightly based on the manufac-
FIGURE 12-2 Instruments used to conduct a general physical exam
Preparing the patient for the examination is a key responsibility of the medical assistant. This begins with the initial contact with the patient. Chapter 11 reviews the procedures for obtaining vital signs and performing a brief patient interview. Upon completion of the patient interview, the patient is properly prepped for the examination. Positioning and draping the patient enables the provider to visually and physically assess the patient and determine a diagnosis.
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H I PA A PAT R O L Be familiar with HIPAA regulations that require offices to provide patients with a private setting when questioning them about confidential subject matter. It is best to obtain all vital signs and personal information in the exam room in order to be HIPAA compliant.
THE PHYSICAL EXAM
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TABLE 12-1 Instruments Used in the Typical Medical Examination INSTRUMENT/SUPPLIES
DESCRIPTION/INDICATIONS
Basin
Serves several purposes: Used instruments may be placed in the basin to be either cleaned or discarded May hold body fluids, such as emesis May be used to collect fluids during irrigations
Drapes
May be paper or fabric Used for patient privacy and comfort
Gloves
May be latex or not (for latex allergies) and may be powdered Different sizes available Learn the different providers’ sizes in your facility
Gowns
May be paper or fabric May be different lengths Depending on the type of exam, may open to the front or back
Fecal occult blood test
A small cardboard testing card along with a bottle of developer Used to evaluate blood in the stool (see Chapter 14)
Lubricants
Usually in a tube; nonsterile Used to increase comfort when performing a manual rectal examination or to lubricate certain instruments for insertion into different body cavities
Ophthalmoscope
Light source to examine eye interior and optic vessels Maintain functional operation of equipment within the exam room
Otoscope
Light source to examine the ear canal and tympanic membranes Ensure that the disposable speculums that attach to the otoscope are stocked for use
Percussion hammer
A small triangular hammer made of hard rubber Used to test reflexes during an examination
Cotton- or rayon-tipped sterile applicators
Many specimens will require the use of a sterile applicator, such as wet mount slides and tissue or cell slides (refer to Chapter 29 for further specimen collection requirements)
Various specimen collection kits or containers
Anticipate which specimens may need to be collected and the specimen collection equipment or supplies needed (refer to Chapters 25 through 30 for more information on specific collection requirements)
Stethoscope
Used for blood pressures and auscultation of body sounds including breath, heart, and bowel
Tape measure
Either in inches or centimeters Used to measure body circumference and length
Tissue
Should be soft and absorbent May be used for patient comfort, cleaning areas where lubricants have been used, and removing body fluids
Tongue depressors
Sterile; used to compress the tongue when inspecting the throat Can also be used during neurological evaluations, such as tracking eye movements
Tuning fork
Used to test for bone and air conduction deafness Important in neurological examinations (see Chapter 13)
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F IEL D S M A R T S
FI E L D S M A R T S
Many medical offices display signs in the waiting or reception area that prohibit the use of cell phones or pagers while in the office. If your office does not, remind patients to turn off cell phones and pagers before the exam begins. This will eliminate delays during the exam and possibly prevent the patient from becoming embarrassed because of a ringing cell phone.
Remember to provide safety and comfort when positioning your patient. Evaluate the mental and physical status of the patient prior to moving away from the exam table. Physically disabled or mentally impaired patients can easily become injured from a fall if left alone. Continually monitor patients and use safety belts when patients are placed in positions that compromise their safety. Offering your hand to help a patient sit up after lying in a prone position will help the patient who cannot sit up without assistance. Obese or weak patients may need assistance in lifting a leg, whereas paraplegic or stroke victims may need assistance in raising their arms.
PATIENT POSITIONING AND DRAPING When preparing the patient for the physical examination or any other procedure, proper positioning and draping will increase access to the patient’s body to facilitate the examination process. Patient comfort and privacy is directly related to correct and thorough positioning. The medical assistant can assist the patient into the position most conducive to the exam while explaining the purpose of this position to the patient. Remember that more than one position may be used during the exam and the medical assistant must be prepared to anticipate position changes in order to provide assistance to the patient and provider. Always stand next to the exam table when positioning the patient and be aware of movements that may cause the patient to lose balance and fall off the exam table. Provide clear and concise instructions on which direction and what body part the patient is to move. It is important to have the patient roll toward you when changing from a supine position to a prone position to be able to stabilize the patient if she is unbalanced. Assist the patient to an upright position and allow the patient time to recover equilibrium when changing positions (Figure 12-3). Some patients suffer from vertigo and can become dizzy or faint due to changes in posture or head positions. Providing adequate draping will ensure warmth and allow the patient to feel more dignified and confident. Patient gowns and drapes should be positioned so that only the portion of the body to be examined is exposed. Again, this may change during the examination, and the medical assistant should be prepared to assist and provide adequate draping for the next portion of the exam. Table 12-2 lists the different examination posi-
tions, gives a description of each, lists the types of exams the positions are used for, and provides a picture for reference. Procedure 12-2 lists the necessary steps for placing a patient into each of the examination positions.
FIGURE 12-3 The medical assistant helps the patient into a sitting position and makes sure that she is steady before allowing her to step down.
THE PHYSICAL EXAM
TABLE 12-2 Patient Positioning POSITION NAME
DESCRIPTION
WHEN POSITION IS USED
Sitting
Sitting on the side or end of the exam table
Obtaining vital signs Reviewing medical history Examining the head and neck Evaluating reflexes Listening to cardiac and breath sounds
Supine
Lying flat on the back
Evaluation of the head, neck, shoulders, chest, abdomen, and extremities Auscultation of abdominal sounds Palpation of thoracic and abdominal regions
Prone
Lying flat on the stomach
Examination of the back and vertebrae Exploration of any skin lesions that are present
Dorsal recumbent
Lying flat on the back with the knees bent and the soles of the feet flat on the table
Examination of vaginal and rectal areas Insertion of a straight or Foley catheter Examination of the head, neck, thorax, and abdominal areas
Sims’
Lying on the left side with the left shoulder placed behind the patient while the right leg is flexed and placed in front of the left leg
Examination of the rectum and vagina Rectal temperatures Enemas Flexible sigmoidoscopy
Semi-Fowler’s
Lying flat on the back with the head raised to a 45° angle
Examination of the head, neck, and upper body Used for patients with respiratory difficulties
Lithotomy
Lying flat on the back with the knees flexed and the feet in stirrups
Examination of the genitals and anal area Gynecological exams and PAP smears
Knee-chest
From the prone position, separate the knees and bring to the chest, raising the buttocks
Examination of the anus and rectum Proctological procedures
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F IELD SM A RTS If a patient feels light-headed or faints while in the office, the patient should be placed in the Trendelenburg position. In this position, the patient is placed on the back with the head of the exam table lowered several inches below the body, in order to promote the flow of blood toward the brain.
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CR ITI C A L TH I N K I N G C H AL LEN G E A 54-year-old male patient is here in the medical office to be seen for his yearly employment exam, which includes an electrocardiogram. The patient explains the difficulty he has in laying flat on his back. If an EKG is not performed, he will not have his driver’s classification renewed for his job. 1. What other position(s) may be suitable for this type of procedure? 2. Should you document that the patient was placed in a position other than the supine for this procedure? Why or why not? 3. What types of items can be used to assist in providing patient comfort?
An exam table belt should be securely fastened around the patient prior to the position change to prevent the patient from sliding off of the table. If the back of the exam table does not recline, elevate the patient’s feet and lower legs. This will also assist with redirecting blood back toward the brain.
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Multiple techniques are employed by the provider during the physical examination. One or all may be used, depending upon the nature of the examination. Table 12-3 explains the six techniques, gives a description of each, and lists examples of what each technique may help to identify. Although the provider performs the actual physical assessment on the patient, the medical assistant will often provide additional assistance to the provider and the patient. Table 12-4 explains the normal sequence of a physical exam. The medical assistant’s role in the exam will vary depending upon the patient’s mobility and the preference of the provider.
Completing the Visit Following the physical exam, the provider will leave instructions on what else needs to be completed before the patient can be dismissed. Instructions may be written in the plan section of the patient’s SOAP note or on the patient encounter form.
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PATIENT ASSESSMENT Whether or not the medical assistant will assist the provider during the actual examination will vary according to the following: the patient’s physical and mental status, the type of exam that needs to be performed, and the preference of the provider. Prior to the exam, the medical assistant should screen the patient, obtain vital signs, allow the patient to empty the bladder, and position and drape the patient. This is all completed in a manner that best facilitates the examination or procedure. The provider will assess the status of the patient.
FI E L D S M A R T S Be sensitive of the patient’s needs and concerns throughout the visit. Take extra time to make certain the patient is properly draped and that you do everything you can to ensure patient comfort. Explaining everything that is going to happen before a procedure or examination begins will help to ease patient anxiety. Encourage patients to alert you if they are uncomfortable or in pain during any part of the exam or procedure so that you can take appropriate responsive measures.
THE PHYSICAL EXAM
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TABLE 12-3 Examination Techniques Used in the Physical Examination TECHNIQUE
DESCRIPTION
EXAMPLES OF WHAT MIGHT BE EVALUATED
Inspection
Frequently used to observe the patient for any signs of pathology that might indicate a disease or disorder. This includes observation of physical, mental, and emotional signs.
Skin lesions Scars Body colors such as cyanosis Speech patterns Gait changes Posturing Anxiety
Auscultation
Involves listening skills using a stethoscope. Many parts of the body emit sounds that provide clues to assist with diagnosis and treatment. This is done before palpation and percussion for best results.
Lung sounds Heart sounds Bowel sounds
Palpation
Touching the body is one way to evaluate tenderness and pain as well as the location and size of internal organs. Some palpation is light in pressure, whereas some involves deeper pressure.
Light palpation: Pain and tenderness Muscle resistance Superficial masses For relaxation Deep palpation: Organ enlargement Organ displacement Deep masses
Percussion
Sounds are evaluated by tapping the fingers on the body. Various sounds reverberate over structures to allow determination of the type of structure involved, either solid, liquid, or gas (air). Dullness indicates fluid or a solid structure. Tympany (a drum-like sound) indicates air or gas.
Size and location of organs Gas Fluids in abdomen Fluids in pleural spaces Liver enlargement
Mensuration
Measurements of different areas of the body, using a tape measure and scales.
Height Weight Length or circumference of a limb Infant chest circumference Infant head circumference continues
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TABLE 12-3 Examination Techniques Used in the Physical Examination (continued) TECHNIQUE
DESCRIPTION
EXAMPLES OF WHAT MIGHT BE EVALUATED
Manipulation
Applying passive movement to a joint while using force.
Range of motion of some joints
TABLE 12-4 The Complete Physical Examination Sequence COMPREHENSIVE EXAMINATION EXAM SECTION TECHNIQUES
MEDICAL ASSISTANT’S RESPONSIBILITIES
PROVIDER’S RESPONSIBILITIES/ DESCRIPTION OF EXAM SECTION
General survey
Inspection
Share with the provider any observations (the process of watching or visualizing) noted when assisting the patient to the exam room (the provider doesn’t always see the patient walk or the difficulty the patient experienced in removing clothing).
This portion of the exam continues throughout the entire physical. It involves observing the general state of health, to include posture (position of the body), gait (the way the patient walks), grooming, odors, facial expressions, speech, and level of awareness.
Vital signs
Auscultation
Assist the patient to a sitting position. Obtain temperature. Obtain pulse and respiration. Obtain blood pressure.
Vitals are obtained by the medical assistant and repeated by the provider if abnormalities are evident.
Skin
Inspection Palpation
Assist the patient with the gown. Provide adequate lighting in the room.
The skin on the face and upper body is observed. Any discolorations are noted, including patterns, locations, and colors. The hair, hands, and nails are inspected and palpated.
HEENT: Head Eyes Ears Nose Throat
Inspection Palpation
Darken the room for the eye exam. Provide working equipment, including ophthalmoscope, batteries for ophthalmoscope, otoscope, tongue depressors, and speculum for nasal evaluation.
This section includes examination of the head, eyes, ears, nose, and throat. Head: scalp, hair, skull, face exam Eyes: The provider assesses the physical parts of the eye. Ears: Inspects auricles, canals, and ear drums; performs gross hearing screening exam Nose: Inspects internal and external nasal cavities; palpates sinuses Throat: Inspects mouth, lips, gums, teeth, tongue, tonsils, and palate
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TABLE 12-4 The Complete Physical Examination Sequence (continued) COMPREHENSIVE EXAMINATION EXAM SECTION TECHNIQUES
MEDICAL ASSISTANT’S RESPONSIBILITIES
PROVIDER’S RESPONSIBILITIES/ DESCRIPTION OF EXAM SECTION
Neck
Inspection Palpation
Remove the gown from the neck region.
This evaluation includes palpating and inspecting the cervical lymph nodes. Masses and pulses are felt. The thyroid gland is palpated at this time.
Back
Inspection Palpation
Open the back of the gown to expose the spine and muscles of the back.
The provider will look at and feel the muscles and vertebra of the back. Alignment will be evaluated.
Posterior thorax and lungs
Inspection Palpation Percussion Auscultation
Provide a stethoscope to the provider.
The spine and muscles of the upper back are palpated and inspected. The provider will percuss each side for dullness. Using the stethoscope, breath sounds will be evaluated.
Breasts
Inspection Palpation
Address comfort levels and privacy. The patient’s gown may be opened to expose the upper chest area. Replace the gown when completed.
Inspection of the breasts (both genders) occurs, followed by palpation of the axillary nodes and epitrochlear nodes. The sitting portion of the breast exam is completed.
Musculoskeletal (upper body)
Inspection Palpation
Assist the provider as requested.
Range of motion can be evaluated. The hands, shoulders, arms, neck, back, and joints are inspected and palpated.
Anterior thorax and lungs
Inspection Palpation Percussion Auscultation
Provide a stethoscope.
The chest region and breath sounds are evaluated. Voice sounds are also assessed. This is similar to the posterior thorax and lung examination.
Cardiovascular system
Auscultation Inspection Palpation
Assist the patient in transition to the semi-Fowler’s position. Lower the patient gown, and provide a drape for comfort and privacy. Provide a stethoscope with a bell attachment and diaphragm. Assist the patient to sitting. As the patient leans forward, provide support and security.
Jugular and carotid pulsations are inspected and palpated. Using the stethoscope, the carotids are evaluated for bruits.
Auscultation
Abdomen
Inspection Palpation Auscultation Percussion
Assist the patient into the supine position. Remove the gown from the abdominal region and drape the area.
While the patient exhales, the provider will listen for murmurs and other abnormalities. The abdomen will be palpated lightly, then more deeply, while being inspected. Bowel sounds will be auscultated. The liver and spleen will be assessed by percussion. The aorta will be palpated, with the pulsations evaluated. continues
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TABLE 12-4 The Complete Physical Examination Sequence (continued) COMPREHENSIVE EXAMINATION EXAM SECTION TECHNIQUES
MEDICAL ASSISTANT’S RESPONSIBILITIES
PROVIDER’S RESPONSIBILITIES/ DESCRIPTION OF EXAM SECTION
Breasts/axillae
Inspection Palpation
Assist the patient in removing the gown from the breast area. Provide coverage when the exam is complete.
The provider will complete the breast exam in the supine position, to include inspection for dimpling and palpation for masses. The axillary nodes are palpated.
Lower extremities
Inspection Palpation
Provide tools for a neurological exam of the lower extremities. Provide a reflex hammer.
Inspection
Allow the patient to sit briefly prior to standing. Assist the patient to a standing position. Provide support with gait if necessary.
The lower extremity pulses are palpated. Area is inspected for edema, ulcerations, and discolorations. Pitting edema is evaluated. Muscle tone and joint deformities are assessed. Sensations and reflexes are tested. The legs are inspected for varicose veins. Muscle tone and alignment is evaluated. The gait may be reexamined at this time.
Nervous system
Inspection
Assist the patient to a sitting or supine position, as requested by the provider.
This section of the examination may be done at various times. It is composed of five components: Mental status Cranial nerves Motor system Sensory system Reflexes
Gynecological exam for women
Inspection Palpation
Prepare tools for examination (see Chapter 17). Assist the patient into the supine position, then place feet in the stirrups. Provide draping for privacy. Put a light in place for the exam. Assist the patient in relaxing for the exam. Assist the patient from the exam table and assist with dressing if needed.
The provider will inspect the external genitalia, vagina, and cervix. A pap smear will be completed at this time. The uterus and ovaries will be palpated. A rectal exam can be completed at this time.
Prostate and rectal exam for men
Inspection Palpation
Assist the patient into the Sims’ position. Provide draping for privacy. Provide an occult blood card if ordered. Have gloves and lubricant available. Assist the patient from the exam table and assist with dressing if needed.
The anal region will be inspected along with the genitalia, if this is not done while the patient is standing. The rectum and prostate are then palpated.
THE PHYSICAL EXAM
Procedures that may be necessary before dismissing the patient include the following: ❖ Performing additional lab or diagnostic testing ❖ Administering or dispensing certain medications ❖ Giving any prescriptions or drug samples to the patient and providing instructions on how to take the medication ❖ Setting up an outside test for the patient ❖ Completing a referral and setting up an appointment with a specialist ❖ Providing the patient with home care instructions ❖ Setting up a new appointment for the patient After performing any necessary procedures, share the results of the procedure with the provider before dismissing the patient. The results may create a change in how the provider wants to proceed. Inform patients of when and how they can receive lab results. Encourage patients to call if they have any other questions. Properly escort the patient to the check-out area and return to the room to prepare it for the next patient. Refer to Procedure 12-3 for a complete procedure on assisting with the general physical exam. The medical assistant can be the support that allows for a smooth, successful, and professional patient examination. Compliance of orders and instructions will correlate to the care provided during the exam.
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H I PA A PAT R O L Many times, patients will want to know when their lab results will be available. This is a good time to review the standard office policy for reporting lab results and to review who can receive this type of confidential information in the event that the patient is unavailable. Document who may receive protected information in the appropriate section of the patient’s chart. Update this information on a regular basis. Marriages, divorces, separations, and such will most likely change who can receive private information.
From initial preparation of the patient room and equipment and continuing through the patient assessment, the medical assistant must demonstrate a high level of professionalism, compassion, empathy, assistance, and education for a quality standard of care required in the medical profession.
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E M R A P P L I C AT I O N With EMR, the medical assistant can set up a new appointment for the patient directly from the point of care. The appointment screen can usually be accessed in most software programs by going into the main menu and clicking on the “Appointments” icon. Having a clinical staff member set up the appointment will help to ensure that the proper amount of time is reserved for the next appointment and will expedite check out procedures when the patient leaves.
C R I T I C A L T H I N K I NG CHALLENGE You are assisting the provider during a Pap and pelvic exam. The patient does not verbally state that she is in discomfort but her facial expressions say otherwise. 1. What should you do when you notice the patient is in quite a bit of discomfort during the examination? 2. How might a thorough explanation of what to expect during the procedure assist in decreasing the patient’s mental outlook during the procedure?
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PROCEDURE 12-1 Prepare the Examination Room Objective: To properly prepare the examination room for a patient coming in for a complete physical exam.
Equipment/Supplies: ❖ ❖ ❖ ❖ ❖ ❖ ❖
Exam table Table paper Disposable gloves Pillows or support cushions Gowns and drapes Cleaning supplies Lighting
PROCEDURAL STEPS
❖ Disposal containers ❖ Biohazard containers ❖ Appropriate instruments and supplies (stethoscope, otoscope, ophthalmoscope, percussion hammer, neurological hammer, pin wheel, hemoccult supplies, lubricant, pelvic exam supplies for a pelvic exam, tissues, tape measure, plenty of tissue) RATIONALE
1. Wash your hands and put on disposable gloves.
This protects the medical assistant when handling contaminated materials. It also provides protection when using disinfectants.
2. Remove any used exam paper and pillow coverings. Discard in an appropriate container.
This prevents any cross-contamination between patients. If body fluids are evident, discard in the biohazard container.
3. Use the designated disinfectant cleaner to wipe the exam table surfaces along with any other trays or countertops that have been used during the previous exam. Always clean from an area of lesser concentration to an area of greater concentration. (Read the label on the disinfectant to make certain that it can be used in an exam room setting. If ventilation requirements are not possible, do not use. Open the window, and put on a mask when cleaning with any products that carry a respiratory warning.)
Disinfectants will remove contaminants from surfaces and help to prevent any cross-contamination. Cleaning from an area of lesser concentration to an area of greater concentration keeps the medical assistant from pulling microorganisms to an area that was not contaminated or that didn’t have as much contamination.
4. Remove gloves, discard, and wash your hands.
Gloves do not need to be worn because you will only be handling clean materials.
5. Place the exam paper on the exam table. Replace the pillow cover with a clean or new cover.
Clean paper and pillow covers are needed for each patient to reduce cross-contamination.
6. Check the function of the exam table. Is it at the correct height? If you have an electronic table, make certain that the selection controls are working properly.
If the exam table is not working properly, it could waste time for the both the provider and the patient.
7. Make sure the lighting is effective.
Good lighting is needed for a thorough inspection.
8. If the exam room contains a sink, be sure paper towels or another method for drying the hands are available and functional.
The provider needs all supplies readily available.
THE PHYSICAL EXAM
PROCEDURAL STEPS 9. Make sure all supplies and equipment necessary for the exam are well stocked and placed in a location easily accessible. Have gowns and drapes available. Have gloves for the provider in place.
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RATIONALE Having supplies readily available saves time.
10. Make one last visual sweep of the exam room to ensure that all equipment and supplies are ready and available for the next patient exam.
A clean, well-stocked exam room reflects positively on the practice.
11. If applicable, activate the room indicator to alert workers that the room is ready for the next patient.
Room indicators may be flags or a light system that can be activated to indicate that the room is ready for the next patient.
PROCEDURE 12-2 Position and Drape the Patient Objective: To assist patients into a variety of common positions that are used for various exams and to drape for privacy.
Equipment/Supplies: ❖ Exam table ❖ Table paper ❖ Disposable gloves if necessary
❖ Patient gown ❖ Paper or cloth drape
PROCEDURAL STEPS
RATIONALE
1. Wash your hands and use gloves if necessary.
Handwashing is the principle method of preventing the spread of infection.
2. Prepare the exam room, positioning the table into a low flat position, if applicable.
The room should be ready prior to allowing the patient to enter. Positioning the table low will eliminate the need for climbing. A lowered table allows for better body mechanics.
3. Identify the patient using two identifiers, identify yourself, and explain the procedure.
It is important to make sure the patient is the correct patient. Educating the patient as to what to expect will encourage patient cooperation.
4. If a gown is to be used, provide this to the patient with instructions on opening in the front or rear. Allow the patient privacy to change into the gown. Provide assistance with gowning if requested.
Depending on the exam, the gown should be worn in a manner that provides exposure for the exam along with the most privacy for the patient. continues
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PROCEDURAL STEPS 5. Pull out the retractable step to allow the patient to step up and be seated safely on the exam table. Once the patient is seated on the exam table, push in the retractable step and assist the patient into one of the following positions: Sitting position: Explain to the patient how to sit. The patient’s legs should be flexed, hanging at a 90º angle over the edge of the table. The thighs should be supported on the exam table. Make certain the patient is sitting in a stable manner and be certain the patient is stable. Provide a drape for privacy and comfort. This should cover the lower extremities and lap area. Supine position: Ask the patient to sit at the end of the exam table.Have the patient lie back on the exam table and extend the table extension to rest the patient’s legs on. Place a pillow under the patient’s head and shoulders, for comfort. Place a drape over the torso and lower extremities for comfort and privacy. Prone position: Ask the patient to sit on the end of the exam table.Have the patient lie back in the supine position and extend the table extension. Instruct the patient to roll toward you and lie on the stomach.Position the patient with the head turned to the side and the arms at the side or above the head. Place a drape on the torso and lower extremities for comfort and privacy. Dorsal recumbent position: Ask the patient to sit on the end of the exam table. Have the patient lie back in the supine position and extend the table extension. Ask the patient to bend the knees and place the feet flat on the table. Push the table extension in. Drape the patient so that one corner of the drape points toward the head and covers the abdominal region and the opposite corner points toward the feet (known as the diamond drape). Sims’ position: Ask the patient to sit on the end of the exam table. Have the patient lie back in the supine position and extend the table extension. Ask the patient to roll toward you up onto the left side. Instruct the patient to place the left arm behind the body and the right arm in front of the body. Both legs are flexed slightly with the top leg flexed at a more extreme angle. Drape the patient for comfort and privacy.
RATIONALE A retractable step helps facilitate the patient’s ascent to the table surface. If a step is not available, a stool that is wide and provides a stable surface may be used. Retracting the step into the table provides a safer floor space for the provider to move freely around the patient without tripping over the step. Using good body mechanics will protect the health of the patient along with the medical assistant. If the patient is unstable, being left alone could result in a fall and injury to the patient. Patient privacy is a minimal requirement for patient care. Unnecessary body exposure makes the patient uncomfortable and decreases the chance of patient cooperation and compliance.
If the pillow is not placed under both the head and shoulders, excessive flexion of the cervical vertebrae could occur.
Rolling the patient toward you will provide stability and prevent the patient from falling off the exam table.
Pushing the table extension back in allows more space for the provider to conduct the exam. The diamond drape covers the patient and provides easy access for the provider when conducting the exam.
Flexing the legs helps to provide easier access to the exam area.
THE PHYSICAL EXAM
PROCEDURAL STEPS Fowler’s position: Ask the patient to sit on the end of the exam table. Elevate the head of the exam table to the desired angle (Fowler’s is a 90° angle and semiFowler’s is a 45° angle). Drape the torso and lower extremities for comfort and privacy. Lithotomy position: Ask the patient to lie in the supine position and pull out the table extension. Extend the stirrups at the end of the exam table and instruct the patient to scoot to the end of the exam table and place the feet in the stirrups; assist the patient, as this is sometimes difficult. Drape the patient with the diamond drape. Knee-chest position: Ask the patient to lie on the exam table in the prone position. Instruct the patient to get on hands and knees and pull the knees as close to the chest as possible. Have the patient turn the head to the side and bend the arms and place them above the head. Drape the patient with the diamond drape. 6. Instruct the patient not to tuck the drape under or around body parts.
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RATIONALE Patients with cardiac or respiratory difficulties are placed in these positions to facilitate easier breathing.
Helping the patient place the feet in the stirrups makes it easier. The diamond drape provides privacy for the patient and the provider needs only to lift one corner of the drape to conduct the examination.
This can be an uncomfortable and embarrassing position for the patient, so do not place them in this position until the provider is in the room. The diamond drape provides privacy for the patient and easy access to the area that is being examined.
A free-lying drape will allow for small movements and adjustments of the drape to provide maximum coverage.
PROCEDURE 12-3 Assist with the General Physical Examination Objective: To assist the provider with all aspects of a complete physical examination.
Equipment/Supplies: ❖ ❖ ❖ ❖
Examination table Table paper Gown Drape
PROCEDURAL STEPS
❖ Examination equipment/tools ❖ Patient medical record/pen ❖ Disposable gloves RATIONALE
1. Prepare the exam room. 2. Wash your hands and use gloves if necessary.
Handwashing is the principle method of preventing the spread of infection. continues
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PROCEDURAL STEPS
RATIONALE
3. Prepare a tray with the equipment necessary for the examination.
Be prepared for what type of exam is being performed. Anticipating the needs of the provider best facilitates the exam and exercises time management.
4. Identify the patient using two identifiers, identify yourself, and explain the examination to the patient.
It is important to make sure you have the correct patient. Educating the patient as to what to expect will relax and comfort the patient.
5. Using the patient record, begin screening the patient and obtain vital signs, height, and weight. 6. Allow the patient to use the restroom and collect a specimen if required.
Using the restroom prior to the exam will be more comfortable for the patient and save time in the event the provider wants immediate results or wants to personally examine the specimen microscopically.
7. Provide a patient gown and drape. Instruct on the proper way to put on the gown. Inform the patient where personal belongings may be placed and request that cell phones and pagers be turned off.
If the patient knows how to properly put on the gown, it will eliminate embarrassment for the patient and also save time.
8. Place the patient in a sitting position and explain to the patient that you will be alerting the provider that the patient is ready for the exam. 9. As the provider examines the patient, assist as necessary. This includes repositioning and draping the patient, handing equipment to the provider, altering lights as required, and chaperoning/reassuring the patient on delicate exams. You may also document items on the patient record as the exam proceeds. 10. Following the examination, assist the patient in sitting and reorienting.
When the medical assistant is present in the room, this provides a secure environment for the patient and protects the provider from false accusations of making improper advances toward the patient.
After lying in a supine or prone position some patients may be dizzy and may need assistance in sitting up. Allow the patient to sit momentarily before moving off of the exam table.
11. Assist the patient from the exam table if needed. Instruct the patient to dress and inform the patient that someone will return to provide further instructions from the provider. 12. Instruct the patient on any directives the provider ordered. Document instructions in the patient record.
Often the patient will forget what the provider ordered. The medical assistant can reinforce verbally and in writing this information. Copies of lab orders and prescriptions should be placed in the record for any future reference.
13. Accompany the patient to the check-out area and reception area.
Accompanying the patient to the check-out area provides time for additional questions from the patient.
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DOCUMENTATION EXAMPLE:
02-13-XX 8:00 a.m.
Patient here for a complete physical today. General concerns include overall fatigue and intermittent joint pain which ranges between 3 and 8 on the pain scale. Pain locations include wrist, shoulders, and knees. Pt. states that there is a family history of arthritis. Pain increases during cold or wet weather. Vital Signs: T: 98.6° F, P: 88, R: 16, BP: 130/88. Erin Speck, CMA (AAMA)
Chapter Summary A complete physical examination involves an inspection of the entire body. Many instruments and supplies are needed in order to conduct this type of exam. It will be the medical assistant’s responsibility to clean and stock the exam room and to make sure that all needed supplies and equipment are available to the provider during the exam. The medical assistant will also need to place the patient in the correct position for each portion of the exam and may be expected to assist the provider during the exam and obtain and process laboratory specimens.
FIELD APPLICATION CHALLENGE A 73-year-old patient has arrived at the clinic to be seen for left hip pain. The patient is in a wheelchair and cannot walk, but can stand.
2. Would the patient be able to remain seated in the wheelchair and not have to disrobe for the examination?
1. How would you prepare and position this patient for best access during the examination process?
3. What special precautions should be taken in positioning and draping this patient for the exam?
Chapter Assessment 1. All of the following are examination techniques except: a. auscultation. b. palpation. c. interpretation. d. inspection.
3. The Sims’ position is used for all of the following except: a. colonoscopy. b. pelvic exam. c. reflex evaluation. d. rectal exam.
2. The lithotomy position is useful in which type of patient exam? a. Neuro exam b. Pap test c. Shoulder exam d. Ear exam
4. A patient that is being seen for an abscess on the lower back would be instructed to put the gown on: a. open in the front. b. open in the back. c. both a and b. d. none of the above.
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5. The cleaning and disinfecting of the exam table should be completed how often? a. After each invasive procedure b. After every patient c. When visibly soiled with body fluids d. All of the above 6. A patient has the right to privacy and the medical assistant can assist in maintaining the patient’s privacy by doing which of the following? a. Asking the patient questions in the hallway b. Asking the patient questions in the exam room c. Asking the patient questions in the reception area d. None of the above 7. The provider performs a spinal and hip placement assessment when using which position? a. Sims’ position b. Semi-Fowler’s position c. Supine position d. Prone position 8. The patient should be instructed to move in which direction when moving from the supine position to the prone position? a. Toward the medical assistant to prevent falling off the table b. Away from the medical assistant to prevent the drape from falling off c. Toward the end of the exam table to prevent falling off the table d. None of the above 9. A male provider will legally require the assistance of a medical assistant in which type of exam? a. Performing a Pap smear on a female patient b. Performing a rectal exam on a male patient c. Performing a throat exam on a female patient d. Performing an ear exam on a male patient 10. The equipment used to view the structures of the eye interior and vessels is the: a. otoscope. b. autoscope. c. ophthalmoscope. d. stethoscope.
Web Activities 1. Do a Web site search for different types of examination equipment and the current market prices for the equipment. 2. Go to the OSHA Web site (www.osha.gov) and review the requirements for safety in using cleaning products in an examination room.
CONNECTION Using your StudyWARE CD-ROM: ❖ Complete the Flash Cards activity for this chapter. ❖ Complete the Quiz for this chapter in Test Mode.
THE DVD LINK On your StudyWARE CD-ROM, go to the DVD Challenge for this chapter. View the DVD clip and respond to the following questions: 1. Pictures make positioning appear easy, but as you observed from the DVD clip, positioning can be quite awkward for both the patient and medical assistant. After viewing this DVD clip, are there any positions that make you uncomfortable? 2. There are two positions that are used for rectal exams. Which position would be the safest and easiest for the patient? 3. The position listed as the Trendelenburg position was not actually the Trendelenburg, but an alternative to the Trendelenburg when the head of the exam table will not recline. This position looked quite awkward for the patient. What might have been a better way to elevate the feet so that the blood would rush back down to the brain?
C H A P T E R
Eye and Ear Exams and Procedures Chapter Outline Types of Providers Who Specialize in Treating Eye Disorders Patient Screening for the Eyes Visual Acuity Testing Screening Distance Visual Acuity Screening Near Visual Acuity Color Vision Screening Contrast Sensitivity Testing Instruments for Vision Testing Eye Instillation Eye Irrigation The Ear
Types of Providers Who Treat Conditions of the Ear Patient Screening for the Ear Hearing Defects Hearing Acuity Gross Hearing Screening Tuning Fork Screening Audiometry Tympanometry Ear Instillation Ear Irrigation
Developmental Objectives After completing this chapter, you should be able to: 1. Correctly spell and define the essential terms. 2. Explain the medical assistant’s role in visual acuity and color vision testing.
13 Essential Terms astigmatism audiologist audiometer auricle cerumen glaucoma hyperopia instillation irrigation Jaeger chart myopia ophthalmic ophthalmologist ophthalmoscope optician optometrist otic otorhinolaryngologist otoscope presbyopia refractive disorder Snellen chart tinnitus tonometer tympanic membrane tympanometer visual acuity
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KEY COMPETENCIES
CAAHEP
ABHES
Snellen Chart Visual Acuity Testing
III.C.3.b.4.e
VI.A.1.a.4.h
Screening Near Visual Acuity
III.C.3.b.4.e
VI.A.1.a.4.h
Ishihara Test for Color Vision
III.C.3.b.4.e
VI.A.1.a.4.h
Eye Instillation
III.C.3.b.4.g
VI.A.1.a.4.m
Eye Irrigation
III.C.3.b.4.e III.C.3.b.4.f
VI.A.1.a.4.b VI.A.1.a.4.h
Ear Instillation
III.C.3.b.4.g
VI.A.1.a.4.m
Ear Irrigation
III.C.3.b.4.e III.C.3.b.4.f
VI.A.1.a.4.b VI.A.1.a.4.h
3. List and describe the different eye charts and list in which instances the medical assistant would use each one. 4. Describe the different types of hearing defects. 5. Explain the different types of hearing acuity tests and procedures performed in the medical office.
Introduction As part of a complete physical exam, the medical assistant may be responsible for performing screening tests involving the eye and ear. Common screening tests performed by the medical assistant include visual acuity testing, both near and distance, as well as color vision assessment. A hearing screening may also be performed as part of the physical exam with the use of an audiometer (an instrument that measures hearing). The provider will use the ophthalmoscope, an instrument used to examine the internal structures of the eye and the otoscope, an instrument used to examine the ear during the physical examination. It is the medical assistant’s responsibility to make sure both are in good working order prior to the examination. Some patients may require instillation or irrigation procedures of the eye and ear. The medical assistant is often responsible for performing these procedures in the office and providing patients with proper instruction for performing the steps at home.
TYPES OF PROVIDERS WHO SPECIALIZE IN TREATING EYE DISORDERS A medical doctor who specializes in treating eye disorders is an ophthalmologist. Ophthalmologists are able to treat refractive disorders (conditions in which the lens and cornea do not bend light correctly, resulting in visual defects), prescribe medications, and perform various types of surgical procedures on the eye. An optometrist is not a medical doctor, but rather a doctor of optometry, and is licensed to perform visual acuity testing and able to prescribe corrective lenses to
EYE AND EAR EXAMS AND PROCEDURES
treat refractive errors. The optician is not a doctor and cannot diagnose, prescribe, or treat eye disorders, but is able to fill prescriptions for eyeglasses and contact lenses. General practitioners often examine the patient’s eyes during routine physicals and following eye injuries (Figure 13-1) and are trained to treat specific eye conditions. A common instrument used to examine the eye is an ophthalmoscope (Figure 13-2). Often times, general practitioners will refer a patient to an eye specialist when the patient’s condition is beyond the practitioner’s scope of duty. The medical assistant’s role during these types of visits will vary but may include asking screening questions prior to the exam, performing visual acuity testing, preparing equipment and supplies for the eye exam, assisting the provider during the exam, and performing treatments ordered by the provider such as eye irrigations or the instillation of eye drops.
FIGURE 13-1 A provider examines a patient’s eye.
FIGURE 13-2 An example of an ophthalmoscope, an instrument used to examine the eye
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PATIENT SCREENING FOR THE EYES Medical assistants may have the responsibility of screening patients prior to examination by the provider. The depth of screening will be established by office protocol, but in general, medical assistants should be able to ask a series of questions related to the patient’s symptoms. Table 13-1 lists types of questions that are typically asked when patients complain of eye symptoms and lists common procedures that coincide with symptoms. Important note: Medical assistants should never perform any procedure unless directed to do so by the provider; however, they can set up various equipment and supplies to help save time in the event that testing is ordered.
VISUAL ACUITY TESTING Visual acuity testing is a screening procedure used to detect possible errors of refraction. As light enters the pupil, the light rays are bent so they can be focused on the retina. An error of refraction causes improper bending of the light rays, preventing proper focusing on the retina. This type of testing may also be performed on patients following an eye injury to determine if vision has been affected as a result of the injury. Some refractive errors are caused by a defect in the shape of the eyeball. Refractive errors include: ❖ Myopia (nearsightedness): The ability to see only objects that are close up ❖ Hyperopia (farsightedness): The ability to see only objects that are far away ❖ Presbyopia: Farsightedness due to the aging process, caused by loss of elasticity of the lens ❖ Astigmatism: Abnormal curvature of the cornea, which causes blurry vision Figure 13-3 illustrates the manner in which light rays focus on the retina in refractive errors. Patients with refraction disorders may opt for a variety of treatments including visual devices, such as eyeglasses and contact lenses, or surgical intervention.
Screening Distance Visual Acuity The Snellen chart (Figure 13-4) is used to test distance visual acuity. This chart is used for adults and school-aged children and consists of different letters in the English alphabet, displayed in decreasing sizes. There are a number of charts that may be used for preliterate children and patients unfamiliar with the English alphabet. The Tumbling E chart consists of
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TABLE 13-1 Patient Screening Questions and Instructions for Assisting Patients with Eye Disorders ASK THE PATIENT: “ARE YOU EXPERIENCING ANY. . .”
Visual disturbances, double vision, light sensitivity, excessive tearing, night blindness, drainage, foreign body in eye, blind spots, halos around objects, or blood shot eyes? Personal or familial history of eye disease? Question the patient regarding the use of contacts and eye glasses and record the date of the patient’s last professional eye exam.
DISROBING INSTRUCTIONS
None
VITAL SIGNS
Blood pressure, temperature
EQUIPMENT
Eye tray, cycloplegics (medications that paralyze the ciliary muscle), fluorescein dye, sterile swabs, 4x4s, pen light, ophthalmoscope, and antibiotic drops. Note: For patient comfort, dim or turn off lights until provider enters the room.
POSSIBLE PROCEDURES
Visual acuity testing, eye irrigation, eye instillation
FIGURE 13-3 Errors in refraction: normal vision, myopia, hyperopia, presbyopia, astigmatism
Normal eye Light rays focus on the retina
Myopia (nearsightedness) Light rays focus in front of the retina
Hyperopia (farsightedness) Light rays focus beyond the retina
Presbyopia Light rays focus behind the retina
Astigmatism Light rays focus on multiple areas of the retina
FIGURE 13-4 A Snellen chart, for screening visual acuity
EYE AND EAR EXAMS AND PROCEDURES
the letter “E” arranged in different directions and in decreasing sizes. The patient is asked to describe which direction the open end of the E is facing (toward the top, toward the bottom, toward the left, or toward the right). Children often point in the direction the open end of the E is facing rather than describing the direction. The Landolt C chart is similar to the Tumbling E chart but features a set of circles with different segments missing from each circle (resembling the letter “C”). The patient describes where each missing segment is located. Also available for testing preschoolers aged three to five years are Snellen numbers and picture tests, such as the Allen object recognition chart and the LEA chart. The HOTV chart (a chart consisting of the four letters HOTV in descending order) is yet another chart that can be used for patients with limited reading skills. For more information on pediatric visual acuity testing, see Chapter 19.
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Visual acuity testing should be conducted in a quiet, well-lit area. Adult patients and children aged six and above are placed 20 feet away from the chart during testing, while pediatric patients aged five and below are placed 10 feet away from the chart. This distance can be marked on the floor with tape or a painted line. Acuity is measured in each eye separately, usually beginning with the right eye, then the left eye, and then both eyes simultaneously, unless, of course, the patient has poorer vision in one eye; in that case the eye with the poorest vision should be tested first (see the Field Smarts tool box on this page).
The patient is instructed to cover one eye with an occluder and begin reading downward from the top of the chart. Instructing the patient to keep both eyes open during testing will help to prevent blurring in the eye that is covered with the occluder. The last or smallest line that the patient is able to read without error is generally the line that is recorded for the measurement; however, this may vary in pediatric procedures. The patient should be observed for any signs of difficulty, such as squinting, watery eyes, or leaning forward. To the left of each line are fractional numbers. The numerator in the fraction represents the distance at which the test is performed. The numerator 20 is used on the standard Snellen chart because the majority of tests are performed at a distance of 20 feet away from the chart. The denominator represents the distance at which patients with normal vision can read the line. If the smallest line the patient can read is the 20/100 line, it means that the patient reads at 20 feet what individuals with normal vision can read at 100 feet. When the test is performed at a distance of 10 feet away from the chart, such as during pediatric testing, the number “10” should be used as the numerator. The results may be recorded in the patient’s chart in the following manner: “R. eye: 20/40, L. eye: 20/50,” and “both eyes: 20/40.” When patients wear corrective lenses, it will be up to the provider to determine whether or not the testing will be performed with or without corrective lenses. When testing is performed with corrective lenses, it should be noted as such in the chart. See Procedure 13-1 for step-by-step instructions for performing visual acuity screening on an adult.
TOOL BOX
TOOL BOX
Performing Visual Acuity Testing
F IEL D S M A R T S
FI E L D S M A R T S
When testing visual acuity on patients with known visual disorders, it may be best to begin the testing in the eye with the poorest vision. This helps prevent patients from intentionally or inadvertently memorizing letters or objects on lines during the screening on the eye with the poorest vision. You can also change the direction that the patient reads the lines; instead of asking the patient to read all lines from left to right, try having the patient read from left to right in one eye and then right to left in the opposite eye.
The abbreviations for the eyes, OD (right eye), OS (left eye), and OU (both eyes), have been placed on the Institute for Safe Medication Practices’ (ISMP) “Error Prone Abbreviations” list. Even though this list pertains to abbreviations used when documenting medications or other types of orders, many offices have prohibited the use of these abbreviations altogether; therefore, when documenting test results or treatments, results should be fully written out or abbreviated as follows: R. eye, L. eye, or both eyes.
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TOOL BOX
CR ITI C A L TH I N K I N G C H AL LEN G E You are conducting a visual acuity test on a patient who is a truck driver. The patient rattles off the letters quickly with little effort. You suspect that the patient may have somehow memorized the letters on the chart prior to testing. What can you do to make certain the patient’s visual acuity is really accurate?
to the small print commonly found in telephone directories. The Jaeger chart is also available in different styles for nonreading and non-English-speaking patients. The patient is instructed to hold the card at a distance of 14 to 16 inches away from the eyes and continue reading to the smallest line possible. That number is then recorded in the patient’s chart. Both eyes should be tested separately. Any differences observed during testing should be noted, as well as whether or not the patient wore corrective lenses. Refer to Procedure 13-2 for instructions on how to perform a near visual acuity screening.
Color Vision Screening Screening Near Visual Acuity Screening for near visual acuity (NVA) measures the patient’s ability to read items at a close distance. The Jaeger chart, commonly used for near vision assessment (Figure 13-5), consists of a series of readings with the type ranging in size from newspaper headline print
Color vision defect screening is not routinely performed, but may be necessary for people whose jobs involve distinguishing colors, such as pilots, truck drivers, and police and fire personnel. A defect in color vision is commonly referred to as “color blindness,” or as color vision deficiency (CVD). This disorder can be inherited, or can be acquired due to eye disease, injury, and certain medications. It can also develop as a result
FIGURE 13-5 When screening for near visual acuity, the patient holds the chart 14 to 16 inches from the eyes.
EYE AND EAR EXAMS AND PROCEDURES
of aging. As a person grows older, the lens of the eye can darken and become yellow, causing problems with distinguishing color. Color vision defects are more common in men. Approximately 8% of males and 1% of females suffer from color vision deficiency. There are different methods used for color vision screening that use color charts or plates known as pseudo-isochromatic test plates. One method commonly used is the Ishihara method.
The Ishihara Method The Ishihara method for screening color vision is used to detect color vision deficiency and red-green deficiency. This method uses color plates containing different sized circles. The circles contain primary colored dots which form a number or a shape against a background of contrasting colored dots (Figure 13-6). The test consists of 14 plates, but only the first 11 plates are used during the basic screening unless the patient misses any of the first 11 plates; in that case, the remaining three plates are used for testing as well. Additional plates or albums may be purchased for more comprehensive testing. The Ishihara test should be performed in a quiet area with natural lighting whenever possible. The test should not be performed under regular incandescent or fluorescent lighting. A specially designed light booth may be used when natural lighting is not an option. Bright light can cause color distortion resulting in inaccurate results. The patient is comfortably seated and the medical assistant holds the plates 30 inches away from the patient and at a right angle to the patient’s line of vision. The medical assistant will ask the patient to identify the design, shape, or number inside the circle or trace the line within the circle. The patient has approximately three seconds to identify each plate. If the patient is unable to identify particular color plates it may indicate that the patient has a color vision deficiency problem (see Procedure 13-3). The medical assistant will record which plates the patient was unable to identify and share the information with
FIGURE 13-6 Ishihara color plates used to test patient’s color vision
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the provider. If a defect is discovered, the patient is generally referred to an ophthalmologist.
Contrast Sensitivity Testing The measurement of contrast sensitivity provides a screening test for earlier diagnosis and treatment of particular eye diseases. All major eye diseases such as glaucoma, cataracts, macular degeneration, and diabetic retinopathy affect contrast sensitivity. Several charts are now available for evaluating contrast sensitivity. The Pelli-Robson chart measures contrast sensitivity by defining the faintest contrast the patient can see (Figure 13-7). The chart consists of large letters of a fixed size in varying contrasts. Another contrast sensitivity chart is the Regan chart. This system consists of several charts with different sized letters in low contrast. These charts are similar to the Snellen chart in decreasing levels of contrast.
Instruments for Vision Testing A vision tester is an instrument that offers simple vision screening in minutes. These testers can perform a variety of tests. The patient simply looks into the tester and
FIGURE 13-7 An example of a Pelli-Robson contrast sensitivity chart (Courtesy of Dr. Denis Pelli, NYU.)
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According to the Glaucoma Research Foundation, glaucoma is the leading cause of blindness. Glaucoma is a group of diseases that eventually may lead to destruction of the optic nerve, which is the nerve that allows us to see. Many patients with glaucoma have increased ocular pressure, although not all patients with glaucoma experience this increased pressure. Intraocular pressure can be checked using an instrument called a tonometer. The majority of individuals with glaucoma are older adults; however, glaucoma can occur in younger adults and some babies are born with glaucoma as well. Prevent Blindness America estimates that over 3 million Americans have glaucoma but only half know that they
the medical assistant displays different visual fields to evaluate both near and distance vision. The Titmus vision tester is a compact electric testing device that uses computer-designed optics to screen visual acuity (Figure 13-8). This method can screen FIGURE 13-8 The medical assistant tests the patient’s visual acuity using a Titmus vision tester.
have it. The disease is more prevalent in African Americans than in Caucasians, and African Americans are more likely to go blind from the disease. Other individuals who are more likely to develop glaucoma include: patients with a family history of the disease, diabetic patients, patients over the age of 60, and patients who are extremely nearsighted. There is usually no pain associated with the disease. Symptoms usually do not occur until the patient starts losing peripheral or side vision, which is why continuous monitoring is so important. Surgical intervention and medication can prevent or delay damage caused from glaucoma but cannot cure it.
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PAT I E N T T U T O R
patients for all common vision problems and may detect problems that testing with a standard wall chart can miss. The instrument uses a series of eight test slides that screen the patient for both distance and near visual acuity, muscle balance, peripheral and intermediate vision, and color and depth perception. The testing process takes approximately five minutes to administer. The medical assistant instructs the patient to look into the viewer and stands beside the instrument to change the visual field selection. A visual occluder is incorporated within the viewer for testing each eye separately.
EYE INSTILLATION Eye instillation is performed for a variety of reasons. Medications are instilled to treat infections and to relieve inflammation, to dilate or constrict the pupil, to anesthetize the eye for examination, and to stimulate circulation in the eye. Some medications or drops are used for a variety of different reasons. It is usually the medical assistant’s responsibility to perform instillation and to instruct the patient on proper technique when drops or ointments are to be administered in the home environment. Medications to be dispensed in the eye come in two forms: sterile drops or sterile ointment. Before instilling drops or ointment in the eye, it is important to make sure the medication is for ophthalmic use only. Instructions for performing eye instillation can be found in Procedure 13-4.
EYE AND EAR EXAMS AND PROCEDURES
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F IEL D S M A R T S Never allow the tip of the dropper or ointment tube to touch the patient’s eye or skin when instilling medication into the eye. This will cause the tip to become contaminated and may spread pathogens to the next patient that receives drops from the same dropper or tube. If the tip does become contaminated, the tube or bottle will need to be discarded and a new one opened.
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CR ITI C A L TH I N K I N G C H AL LEN G E The provider orders you to instill antibiotic drops into a patient with a bacterial infection of the right eye. The same medication will be going home with the patient because the provider wants the patient to instill drops in the same eye over the next three days. While instilling the drops, the patient raises his head and contaminates the tip of the dropper. 1. Can the same medication and dropper be used by the patient once the patient goes home? Why or why not?
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EYE IRRIGATION An eye irrigation is performed to flush the eye and may be ordered to relieve inflammation, remove foreign particles, cleanse and remove secretions due to infection, and flush out harmful substances such as chemicals. Eyes contaminated from chemicals are usually flushed with water from an eyewash station. Common solutions used to irrigate the eye include lactated ringer’s solution, sterile saline, and water. The pH of tears is approximately 7.1, normal saline is 4.5 to 7.0, and lactated ringer’s solution is 6.0 to 7.5. Lactated ringer’s solution is highly recommended because its pH is closest to the pH of tears. Properly balanced irrigation solutions are commercially available as well. The solution that is ordered will be based on the patient’s symptoms and the preference of the provider. Equipment that may be used for eye irrigations includes a rubber bulb syringe or water pick. Patients should either lie in a supine position or sit up with their face turned to the side of the eye being irrigated. A basin is usually placed underneath the eye to catch the solution. Waterproof pads should be placed over the patient to keep the solution from running onto the patient’s clothes. The eyes should be irrigated from the inner canthus (corner) of the eye to the outer canthus, keeping debris or bacteria from reentering the eye. Refer to Procedure 13-5 for a complete procedure for irrigating the eye.
THE EAR The ear is the organ responsible for hearing and maintaining equilibrium. It is divided into three main parts: the external ear, the middle ear, and the internal ear, which has many parts (Figure 13-9).
Stapes and footplate Incus
FIGURE 13-9 Parts of the ear Semicircular canals Branches of vestibulocochlear nerve
Malleus Auricle Tympanic membrane
Cochlea
External auditory canal
Oval window
Round window Auditory (eustachian) tube External Ear
Middle Ear
Internal Ear
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External ear structures include: ❖ Auricle or pinna: The visible portion of the ear, made up of cartilage covered with skin. The auricle receives and collects sound waves. ❖ External auditory canal: The passageway, approximately 1 inch in length, lined with hair and glands that produce cerumen (ear wax), that connects the auricle to the tympanic membrane. ❖ Tympanic membrane or eardrum: This membrane separates the external ear from the middle ear and receives sound waves collected by the auricle. The otoscope is used to visualize the tympanic membrane for irritation or perforation (Figure 13-10).
TYPES OF PROVIDERS WHO TREAT CONDITIONS OF THE EAR A medical doctor who specializes in disorders of the ear is an ear, nose, and throat (ENT) doctor. The medical FIGURE 13-10 An otoscope
name for an ENT is otorhinolarygnologist. A general practitioner is also trained to treat mild disorders of the ear such as ear infections. An audiologist is a health care professional trained to identify and treat hearing or balance problems. Audiologists must now possess a minimum of a doctoral degree; however, it does not have to be a medical doctorate. These specialists work closely with ENTs and hearing-aid manufacturers and are often responsible for hearing testing and the dispensing of hearing aids and assistive listening devices.
PATIENT SCREENING FOR THE EAR The medical assistant may be responsible for screening ear conditions. The depth of screening will be established by office protocol, but in general, medical assistants should be able to ask a series of questions related to the patient’s symptoms. Table 13-2 lists types of questions that are typically asked when patients complain of ear symptoms and lists common procedures that coincide with symptoms. Important note: Medical assistants should never perform any procedure unless directed to do so by the provider; however, they can set up various equipment and supplies to help save time in the event that testing or procedures are ordered.
HEARING DEFECTS A hearing loss or defect can be classified as a conduction loss or a nerve loss. Conduction loss occurs when sound waves cannot reach the middle ear due to impacted cerumen, obstruction of the ear canal due to the presence of foreign bodies or polyps, or swelling due to otitis media. A scarred tympanic membrane
TABLE 13-2 Patient Screening Questions and Instructions for Assisting Patients with Ear Conditions ASK THE PATIENT: “ARE YOU EXPERIENCING ANY. . .”
Hearing deficits, ringing in the ear, pain or discharge, build up of earwax, or a possible foreign body in the ear? Do you have a history of ear disorders?
DISROBING INSTRUCTIONS
None
VITAL SIGNS
Blood pressure, temperature
EQUIPMENT
Otoscope, ear tray, ear medication, irrigating equipment and solution (if buildup of cerumen or a foreign body in the ear), audiometer (to measure hearing)
POSSIBLE PROCEDURES
Ear irrigation, ear instillation
EYE AND EAR EXAMS AND PROCEDURES
may also cause conduction deafness. This type of deafness is often treatable. Nerve deafness occurs as a result of damage to the inner ear or the auditory nerve, which blocks the transmission of sound waves to the auditory centers in the brain. Heredity, damage from infectious diseases such as measles or mumps, prolonged exposure to loud noise, tumors, and degeneration due to aging are causes of nerve deafness. Some patients may have a hearing loss from both conductive and nerve defects. This is referred to as a mixed hearing loss. Children should be evaluated periodically to determine if they have any hearing deficits. Hearing deficits can interfere with learning, which causes the child to do poorly in school. Table 13-3 lists some of the problems related to hearing loss.
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FIELD SMARTS You can look for certain signs from patients that may indicate a hearing loss. If any of the following signs are observed, the provider should be alerted: ❖ The patient speaks in a loud voice that is inappropriate. ❖ The patient frequently asks you to repeat what was said. ❖ The patient does not respond when spoken to. ❖ The patient does not pronounce words well. ❖ The patient responds only when spoken to in a loud voice.
HEARING ACUITY
Complaints from patients that should be reported to the provider:
Hearing acuity may be performed by an audiologist or a medical assistant. Several methods may be employed to measure hearing acuity. Some are simple gross screenings that use a tuning fork, while others involve the use of a specialized unit known as an audiometer. During any hearing acuity evaluation, ears are tested one at a time and the ear not being tested should be covered to drown out extraneous sounds.
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Injury to the ear Ringing in the ears, or tinnitus Decreased hearing in either ear Bleeding or discharge from the ear Any noise in the ear or a “full” feeling in the ear
Gross Hearing Screening A gross screening is usually performed by the provider during the physical exam. The provider stands 1 to 2 feet away from the patient and whispers a series of words or numbers. The patient is asked to repeat the words or numbers. Another gross screening involves holding a ticking wristwatch 4 to 6 inches away from the ear to determine hearing ability. Further testing is indicated if a defect is found upon gross screening.
Tuning Fork Screening A tuning fork can be used to screen for general hearing. Two common methods known as the Weber test and the Rinne test are performed by the provider. The Weber test is performed in patients who can hear better in one ear than the other. It involves placing the base of a vibrating tuning fork against the crown of the head (Figure 13-11a). The patient is asked where the
TABLE 13-3 Problems Associated with the Degree of Hearing Loss DEGREE OF HEARING LOSS
ASSOCIATED PROBLEMS
Mild
May not hear soft speech. Child may become fatigued after trying to listen for a long period of time.
Moderate
May affect language development, articulation, interaction with peers, and self-esteem. Child may have difficulty hearing some conversational speech.
Moderate-severe
Difficulty with speech. Does not hear most conversational speech.
Severe
May affect voice quality.
Profound (deafness)
Both speech and language deteriorate.
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FIGURE 13-11a During the Weber test, a tuning fork is held against the crown of patient’s head to determine which ear can hear the sound best.
FIGURE 13-11b During the Rinne test, a tuning fork is placed on the mastoid bone, behind the ear, to determine bone conduction of sound.
sound is heard best. Normal hearing is indicated if the sound is heard equally in both ears. A conduction loss is indicated if the patient can hear the sound better in the affected ear, and a sensorineural hearing loss is indicated if the patient can hear the sound better in the unaffected ear. The Rinne test compares air conduction to bone conduction. During the bone conduction test, the stem of the tuning fork is struck and placed against the mastoid bone behind the ear (Figure 13-11b). The patient is instructed to alert the provider when he can no longer hear the sound. The vibrating tuning fork is immediately moved to the front of the auditory opening for the air conduction test (Figure 13-11c). A patient with normal hearing will be able to hear the sound twice as long by air conduction than by bone conduction. If the patient has a hearing loss caused by a conduction defect, the patient will hear the sound longer by bone conduction than air conduction. If the patient has a sensorineural hearing loss the patient will hear the sound longer during the air conduction portion of the exam but not for nearly as long as in patients with normal hearing.
Audiometry The audiometer is a specialized instrument that measures hearing acuity at different frequencies. It provides information about the extent of hearing loss and which frequencies are involved. Sound amplitude is measured in decibels (dB) and sound frequency is measured in
FIGURE 13-11c During the Rinne test, a tuning fork is held an inch from the patient’s ear to determine air conduction of sound.
hertz (Hz). Figure 13-12 illustrates the decibel volume of selected environments and machinery. Testing must be conducted in a quiet area so that external noise does not interfere with testing. The patient is seated in a direction facing away from the unit and medical assistant. Earphones are placed over the patient’s ears. The patient is asked to raise a hand on the side of the head where the sound is heard. The medical assistant adjusts the machine from the lowest frequency of 250 Hz and gradually increases the frequency until the highest pitch or frequency is reached, around 8000 Hz. Each ear is tested separately, and should be tested in an alternating manner so that the patient doesn’t pick up on a specific pattern. Once the testing process is completed, an audiogram is produced by plotting the results on a graph. Figure 13-13 shows a patient being tested using an audiometer. This is just one example of an audiometer. Numerous models from several manufacturers are available for use in the medical office. Figure 13-14 shows an example of a manual audiometer commonly used in the medical office.
Tympanometry Tympanometry is a procedure used to determine whether or not the middle ear is transmitting sound waves. This procedure is useful in diagnosing middle ear infections that commonly cause hearing loss in children. The tympanometer is an electronic device with an attached probe that is placed snugly in the patient’s
EYE AND EAR EXAMS AND PROCEDURES
Press
Normal conversation
0
10
Weakest sound we can hear
20
30
Quiet bedroom
40
50
60
70
80
90
100
Manual machining
Air-cooled electric motor 50 kw
289
Pain begins
110
120
130
140
150
160
Course grinding Power In the vicinity saw of a jet plane taking off
Insulated lounge
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Spray painting
170
180
190
Sound level dB(A)
Highest sound level that can occur (194 dB)
FIGURE 13-12 Noise levels associated with different environments and machinery
FIGURE 13-13 The medical assistant tests a patient with an
FIGURE 13-14 An example of a manual audiometer (Courtesy
audiometer.
of Welch Allyn.)
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the tympanic membrane. The medical assistant must be sure that the medication is for otic use before instillation.
EAR IRRIGATION Ear irrigation involves washing the external ear canal with a stream of solution. This procedure (see Procedure 13-7) is performed to dislodge a foreign object, cleanse the ear canal, remove impacted cerumen, or reduce inflammation. Impacted cerumen may be softened with mineral oil or hydrogen peroxide prior to removal. An irrigation is contraindicated if the tym-
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FI E L D S M A R T S FIGURE 13-15 An example of a portable tympanometer. This model tests in one second and prints results that can help the provider diagnose otitis media and other middle ear conditions. (Courtesy of Welch Allyn.)
ear (Figure 13-15). Pressure is applied in the ear canal while low-frequency sounds are transmitted. A recording or tympanogram is produced. Peaks and waves are measured to determine possible abnormalities in the middle ear. In a normal ear, the eardrum will vibrate due to the pressure. If fluid is present in the ear, the eardrum will not move.
EAR INSTILLATION Liquids are instilled into the external auditory canal to treat infections, to relieve pain, and to soften impacted cerumen for easier removal. The medical assistant will usually perform the instillation and must be familiar with ear anatomy to ensure correct delivery of the medication (see Procedure 13-6). The ear canal forms an S-shaped curve as it leads inward and it must be straightened to ensure that the medication reaches
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F IEL D S M A R T S When performing an ear instillation or irrigation on an adult or child above the age of three, the ear canal can be straightened by pulling up and back on the auricle. For children under the age of three, the auricle should be pulled down and back.
The most common irrigation solution used for the ears is water. Saline is also sometimes used. Irrigation solutions should be warmed to body temperature whenever possible (approximately 99°F to 100°F (37ºC to 38ºC). Solutions that are cooler or warmer than body temperature may cause the patient to experience dizziness and/or nausea. Extremely hot or cold solutions can damage the eardrum. Use a thermometer to test the temperature of the solution before administering the treatment. When irrigating with saline, place the saline solution in a bowl and warm it in the microwave. Always check the temperature after removal from the microwave to make certain it falls within acceptable parameters prior to inserting the saline solution into the patient’s ear.
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C R I T I C A L T H I N K I NG CHALLENGE The physician orders an ear irrigation on the patient. The order states that the solution should be warmed to 99°F (37°C). You set up all the supplies, warm the solution, and fill the syringe. As you begin the flow of solution into the patient’s ear, the patient complains of pain and extreme dizziness. 1. What may be causing the patient’s discomfort? 2. What could have been done to prevent this problem?
EYE AND EAR EXAMS AND PROCEDURES
panic membrane is perforated, as this could cause an irritation or infection of the middle ear. Different types of irrigating systems include: ❖ Pomeroy syringe: A metal syringe that is filled with irrigating solution. The tip of the syringe is placed in the ear canal and the plunger is depressed to push the fluid into the ear. ❖ Waterpik system: The oral irrigator can be converted into an ear irrigator by using the proper tip for ears. ❖ Electronic ear irrigator: There are several of these systems on the market; they come equipped
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with pressure controls and suction equipment to remove debris as it is dislodged. These irrigators are designed so that the stream of solution is directed to the wall of the ear canal to prevent damage to the eardrum. ❖ Elephant ear wash: This device is convenient and easy to use. It consists of a spray bottle with tubing attached to a nozzle. The bottle is filled with warm water and as the medical assistant pumps the trigger, it sprays the water into the ear with enough pressure to clean the ear, but doesn’t cause discomfort or damage.
PROCEDURE 13-1 Snellen Chart Visual Acuity Testing Objective: To screen for distance visual acuity.
Equipment/Supplies: ❖ Snellen eye chart ❖ Occluder
❖ Alcohol wipes
PROCEDURAL STEPS
RATIONALE
1. Wash your hands and assemble the equipment. Clean the occluder with an alcohol wipe and allow it to air dry.
The occluder should be cleaned before and after testing to prevent patient-to-patient cross-contamination.
2. Identify the patient using two identifiers, identify yourself, and explain the procedure. If the patient wears contact lenses, testing should be conducted with contacts. If the patient wears glasses, testing may be conducted both with and without glasses.
Patients needing corrective lenses will definitely have difficulty seeing the chart without their glasses or contacts.
3. In a well-lit area, instruct the patient to stand at the mark placed 20 feet from the eye chart. Ask the patient to cover the left eye with the occluder (Figure 13-16). Ask the patient to read the chart aloud (keeping both eyes open), beginning with the 20/200 line or with one of the several lines above the 20/20 line.
Closing the eye covered by the occluder can cause squinting in the eye being tested and may also cause the eye covered by the occluder to become blurry before it is tested. Beginning the testing with one of the higher lines helps the patient get into a routine and feel confident about the testing.
4. Stand next to the chart and point to each line during testing (Figure 13-17).
Pointing to the line being read helps to narrow the field of vision to one row at a time. continues
FIGURE 13-16 The patient covers her left eye with an occluder.
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FIGURE 13-17 The medical assistant points to the line the patient is to read.
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PROCEDURAL STEPS
RATIONALE
5. Record the results as the last line the patient can read without errors. Acuity is recorded as a fraction as follows: R. eye 20/10, L. eye 20/30, both eyes 20/20.
The medical assistant must pay close attention while the patient is reading to ensure accurate results.
6. The patient should be observed during the screening for signs of difficulty such as squinting, watering of the eyes, or repositioning of the head.
Any of these signs could indicate a vision problem. If the patient squints or leans forward, it could change the outcome of the test.
7. After screening the right eye, repeat the procedure for the left eye and then with both eyes. 8. Clean the occluder with alcohol, wash your hands, and document results in the patient’s chart.
Occluder must be cleaned after each use to prevent cross-contamination.
DOCUMENTATION EXAMPLE:
08-12-XX 1:10 p.m.
Snellen visual screening per Dr. Kelly. R. eye 20/10, L. eye 20/30, both eyes 20/20. Patient was observed squinting during testing of both eyes. Lillian Kelly, CMA (AAMA)
PROCEDURE 13-2 Screen Near Visual Acuity Objective: To screen near visual acuity.
Equipment/Supplies: ❖ Jaeger near visual acuity chart ❖ Occluder
❖ Alcohol wipes
PROCEDURAL STEPS
RATIONALE
1. Wash your hands, assemble the equipment, and clean the occluder with an alcohol wipe.
Hands must be washed before and after each patient to prevent cross-contamination. The occluder must be cleaned before and after each patient for the same reason.
2. Identify the patient using two identifiers, identify yourself, and explain the procedure.
A clear explanation of the procedure will ensure accurate test results.
3. With the patient in a sitting position, instruct the patient to hold the card approximately 14 inches from the eyes (Figure 13-18).
This is the distance at which a person with normal vision is able to read small print.
FIGURE 13-18 The patient’s near visual acuity is assessed using the Jaeger chart.
EYE AND EAR EXAMS AND PROCEDURES
PROCEDURAL STEPS 4. Instruct the patient to cover the left eye with the occluder and read the chart (out loud) with the right eye.
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RATIONALE Each eye should be tested separately for accurate results.
5. Record the results as the last line the patient can read without errors. 6. Repeat the procedure for the left eye and both eyes together. The patient should be tested with and without corrective lenses, if worn. (Do not have the patient remove contacts.) 7. Wipe the occluder with an alcohol wipe.
The occluder should be cleansed with alcohol to prevent patient-to-patient cross-contamination.
8. Wash your hands and document results in the patient’s chart.
DOCUMENTATION EXAMPLE:
11-08-XX 12:30 p.m.
Jaeger near visual acuity screening per Dr. Price. R. eye, No. 10 (2.25M), L. eye, No. 7 (1.5M), both eyes, No. 6 (1.25M) with corr. Lillian Kelly, CMA (AAMA)
PROCEDURE 13-3 Ishihara Test for Color Vision Objective: To assess a patient’s color vision.
Equipment/Supplies: ❖ Ishihara plates PROCEDURAL STEPS
RATIONALE
1. Wash your hands and assemble the equipment.
Hands must be washed before and after each patient contact to prevent the possible spread of infection.
2. Identify the patient using two identifiers, identify yourself, and explain the procedure. The test should be conducted in a room illuminated by daylight.
Direct sunlight or harsh electric light can distort the color plates.
3. Starting with the practice plate as an example, hold the plate 30 inches from the patient and at a right angle to the patient’s field of vision (Figure 13-19). Instruct the patient to identify the number formed by the colored dots. Patient should only have three seconds to read each line. FIGURE 13-19 The patient’s color vision acuity is tested using Ishihara plates. continues
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PROCEDURAL STEPS
RATIONALE
4. Repeat the procedure with all plates. Note: Some lines will have a winding line that the patient will need to trace rather than a number to read. Record the results after each plate.
List the plate number and the number identified by the patient. Ex: Plate 4:12. If a patient can’t identify the plate, results would be recorded with an “X,” such as Plate 6:X, or just list the plates that the patient could not identify correctly.
5. Protect the plates from light when not in use.
Exposure to direct sunlight can cause fading of the color plates.
6. Wash your hands and document results in the patient’s chart.
DOCUMENTATION EXAMPLE:
01-11-XX 11:30 a.m.
Ishahara color vision screening per Dr. Bell. Plate 4:X, all other plates correctly identified, Jacob Heller, CMA (AAMA)
PROCEDURE 13-4 Eye Instillation Objective: To instill liquid or ointment ophthalmic medication into the eyes to treat infection, anesthetize the eye prior to a procedure, soothe eye irritation, or dilate the pupils for examination.
Equipment/Supplies: ❖ Disposable gloves ❖ Sterile gauze ❖ Disposable eye dropper
❖ Disposable ophthalmic medication ❖ Sterile tissues
PROCEDURAL STEPS
RATIONALE
1. Wash your hands and assemble the equipment. If the medication has been refrigerated, it must come to room temperature before instilling.
Bringing the medication to room temperature before instilling is more comfortable for the patient.
2. Check medication against the provider’s orders and look for the word ophthalmic on the label. Check the expiration date and check the label three times before administration.
Sometimes, the same medication comes in different forms. Never instill a medication into the eye that is not intended for ophthalmic use. Check the label when taking the medication from the shelf, before withdrawing the medication, and before administering.
3. Identify the patient using two identifiers, identify yourself, and explain the procedure. 4. Wash your hands and apply gloves.
Gloves must be worn if blood or body fluid exposure is possible.
EYE AND EAR EXAMS AND PROCEDURES
PROCEDURAL STEPS
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RATIONALE
5. Place the patient in a sitting or lying position and prepare the medication. For eyedrops, withdraw the medication into a sterile dropper. For eye ointment, remove the cap from the tube.
Do not allow the dropper to touch anything other than the solution inside the bottle and do not touch the tip of the ointment tube to the eye.
6. Instruct the patient to look up at the ceiling. With your fingers over a tissue, gently pull down on skin to expose the lower conjunctival sac (Figure 13-20).
Looking up discourages the patient from blinking when drops are instilled.
7. Instill the correct number of drops into the center of the lower conjunctival sac or place a thin line of ointment along the lower surface of the eyelid. Do not touch the tip of the medication applicator to the eye.
If the tip of the eyedropper or the tip of the ointment tube touches the eye, it is considered contaminated.
8. Instruct the patient to close the eye and roll the eyeball around.
Rolling the eye helps to evenly distribute the medication.
9. Dab excess solution from the eyelid with gauze.
Dabbing removes any excess medication.
10. Do not return any unused medication to the bottle. Discard the unused medication, and return the dropper to the bottle without touching the dropper to the outside of the bottle.
FIGURE 13-20 The patient looks up as the medical assistant instills eyedrops.
Touching the outside of the bottle with the dropper will contaminate it. Unused solution should not be returned to the bottle as the remaining medication will be contaminated.
11. Discard used equipment and supplies. 12. Remove gloves and wash your hands.
Hands must be washed after removing gloves to remove any contamination from inside the gloves.
13. Record the procedure in the patient’s chart.
DOCUMENTATION EXAMPLE:
12-14-XX 12:15 p.m.
Visine, 2 gtt R. eye per Dr. Gamble. Pt. tolerated procedure well. Pt. to RTO in 10 days. Anne Zeller, CMA (AAMA)
PROCEDURE 13-5 Eye Irrigation Objective: To flush the eye with solution to remove a foreign object, soothe irritation, apply an antiseptic, or cleanse drainage from the eye.
Equipment/Supplies: ❖ ❖ ❖ ❖
Disposable gloves Sterile irrigation solution Water pick Basin
❖ Disposable towel ❖ Sterile gauze ❖ Towel continues
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PROCEDURAL STEPS 1. Wash your hands and assemble the equipment. Note: if both eyes are to be irrigated, separate supplies will be needed for each eye.
RATIONALE Separate supplies are used to prevent cross-contamination.
2. Identify the patient using two identifiers, identify yourself, and explain the procedure. 3. Place the patient in a sitting or supine position with the head turned toward the affected eye.
This position allows for solution to flow from the affected eye into a basin and avoids cross-contamination from one eye to the other.
4. Check the expiration date of the solution and check the label three times. Note: Solution should be warmed to body temperature (98.6°F or 37ºC).
Warming the solution to body temperature makes the procedure more comfortable for the patient.
5. Place a towel on the patient’s shoulder and place a basin beside the affected eye. Wash your hands again and apply gloves.
The towel protects the patient’s clothing. This position allows the solution to easily flow into the basin.
6. Cleanse the eyelid from the inner to outer canthus with moistened gauze. Discard the gauze after each cleansing.
Cleansing removes any debris or discharge from the eyelid.
7. Prepare a water pick with irrigating solution and hold the eye open with the index finger and thumb.
The patient will have a tendency to close the eye if it is not held open.
8. Rest the bulb of the water pick on the bridge of the patient’s nose. Be careful not to touch the eye or conjunctiva with the tip of the water pick.
Touching the eye will cause contamination of the water pick.
9. Instruct the patient to stare at a fixed spot and open the water pick valve, allowing the solution to flow along the lower conjunctiva from the inner to outer canthus and into the basin (Figure 13-21).
Allowing the solution to flow from the inner to outer canthus eliminates cross-contamination from one eye to the other.
FIGURE 13-21 The medical assistant performs an eye irrigation using a water pick.
10. After irrigation is complete, dry the eyelid and eyelashes from the inner to outer canthus with gauze.
Drying the eyelid removes excess irrigating solution.
11. Discard supplies in an appropriate container. 12. Remove gloves, wash your hands, and document the procedure in the patient’s chart.
DOCUMENTATION EXAMPLE:
05-22-XX 2:30 p.m.
Eye irrigation. 600 cc normal sterile saline, L. eye per Dr. Black. Return solution clear. Pt. tolerated procedure well. Jane Barnes, CMA (AAMA)
EYE AND EAR EXAMS AND PROCEDURES
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PROCEDURE 13-6 Ear Instillation Objective: To instill a solution or medication to treat infection, relieve pain, or soften cerumen for removal.
Equipment/Supplies: ❖ Disposable gloves ❖ Otic solution or medication
❖ Sterile ear dropper ❖ Cotton balls
PROCEDURAL STEPS
RATIONALE
1. Wash your hands and assemble the equipment. 2. Identify the patient using two identifiers, identify yourself, and explain the procedure. 3. Check the medication against the provider’s orders and check the medication three times. Check the expiration date of the medication and verify that the medication is for otic use.
Checking the medication three times reduces the chances for error. Some medications come in different forms. Never instill a medication into the ear that is not intended for otic use.
4. Instruct the patient to lie on the unaffected side or sit with head slightly tilted toward the unaffected side. Place a towel on the patient’s shoulder.
Tilting the head improves the flow of medication into the ear canal and also prevents medication from leaking out after instillation.
5. Apply gloves and withdraw the medication into a sterile dropper.
Using a sterile dropper will ensure that excess contamination will not be introduced into the ear.
6. Grasp the top of the ear and pull up and back for adults, or grasp the earlobe and pull down and back for children under three (Figure 13-22).
Pulling on the ear straightens the canal for easier flow of medication.
7. Instill the prescribed amount of medication into the ear canal by depressing the rubber bulb of the dropper. Do not touch the tip of the dropper to the ear.
Touching the ear with the dropper will contaminate the dropper.
8. Instruct the patient to keep the head tilted for approximately five minutes.
Keeping the head tilted distributes the medication and prevents it from leaking out.
9. Insert a slightly moistened cotton ball into the ear canal per the provider’s orders and instruct the patient to leave it in place for 15 minutes.
Moist cotton will not absorb medication and will prevent leakage when the patient is ambulatory.
FIGURE 13-22
10. Dispose of used equipment and supplies. 11. Remove gloves and wash your hands. 12. Document the procedure in the patient’s chart.
DOCUMENTATION EXAMPLE:
12-20-XX 10:15 a.m.
Auralgan, 3 gtt both ears per Dr. Leonard. Pt. given home instructions. Andy Price, RMA
Eardrops are instilled into the ear canal.
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PROCEDURE 13-7 Ear Irrigation Objective: Removal of foreign matter, discharge, or impacted cerumen from the ear canal.
Equipment/Supplies: ❖ ❖ ❖ ❖ ❖
Disposable gloves Elephant ear wash Container for irrigating solution Ear or emesis basin Irrigating solution warmed to body temperature
PROCEDURAL STEPS
❖ Towel ❖ Cotton balls ❖ Otoscope
RATIONALE
1. Wash your hands and assemble the equipment (Figure 13-23). Check the expiration date of the irrigating solution and check the label three times.
Use of outdated solution could cause further contamination of ear canal.
2. Identify the patient using two identifiers, identify yourself, and explain the procedure. Remember to tell the patient there may be minimal discomfort and some dizziness due to the flow of solution against the tympanic membrane.
Explaining the procedure will assist the patient in knowing what to expect.
3. Place the patient in a sitting position with the head tilted to the affected side.
Tilting the head promotes better drainage of solution out of the ear canal.
4. Place a towel on the patient’s shoulder and instruct the patient to hold an ear basin under the affected ear and against the neck (Figure 13-24). 5. Fill a sprayer bottle with irrigating solution (approximately 30 to 50 mL) warmed to approximately 99°F to 100°F (37ºC to 38ºC). 6. Apply gloves. Cleanse the outer ear with a cotton ball moistened with irrigating solution.
Cleansing the outer ear prevents introduction of foreign matter during irrigation.
7. Gently pull the top of the ear up and back.
This straightens the ear canal.
8. Insert the tip of the sprayer tubing into the ear canal. Slowly, spray irrigating solution so it flows up toward the roof of the ear canal.
Allowing the solution to flow too forcefully onto the tympanic membrane can be painful and can cause injury.
FIGURE 13-24 FIGURE 13-23 Equipment and supplies used to perform an ear irrigation
The patient holds an ear basin under the ear that is being irrigated. continues
EYE AND EAR EXAMS AND PROCEDURES
PROCEDURAL STEPS
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9. Continue the process until the desired effects are obtained. 10. Dry the outer ear and check the inner ear with an otoscope to determine removal of foreign matter.
You want to make certain that the canal is clear.
11. Remove the towel and ear basin and have the patient lie on the affected side on the exam table for approximately five minutes.
This allows for any remaining solution to drain out.
12. Dispose of used equipment and supplies. 13. Remove gloves and wash your hands. 14. Document the procedure in the patient’s chart.
DOCUMENTATION EXAMPLE:
02-24-XX 11:00 a.m.
Irrigated both ears with normal saline. Solution warmed to 99°F per Dr. Peters. Pt. tol. proc. well. No dizziness or nausea following irrigation. Return basin for L. ear had 2 large pieces of cerumen and one small piece. Return basin for R. ear had 1 large piece of cerumen and 2 smaller pieces. Post exam of ears with otoscope appeared clear per Dr. Peters. Miriam Pentella, CMA (AAMA)
Chapter Summary The eyes and the ears are critical to a person’s existence. Without sight and sound, the world can be a confusing and dark place. There are many screening methods available today that can detect vision and hearing problems in their early stages. It is vitally important for the medical assistant be diligent when performing these screening tests. The medical assistant may be the first person to detect a problem and be able to alert the provider to the need for further investigation and testing. Eye and ear procedures such as irrigations and instillations are often performed by the medical assistant. Improper administration of these procedures could cause great harm to the patient; therefore, the medical assistant should be very cautious when performing these procedures.
FIELD APPLICATION CHALLENGE The physician orders an eye irrigation to flush a foreign body from a patient’s right eye. You prepare all equipment and explain the procedure to the patient. You instruct the patient to lie on the back with the head turned to the left side. You then irrigate the eye from the outer to the inner canthus of the right eye. Upon completion, the patient complains of pain in the left eye.
1. Did you follow correct procedure for irrigating the eye? 2. What is the probable of cause of the pain in the left eye? 3. What should you do to correct the situation?
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Chapter Assessment 1. The leading cause of blindness is known as: a. stye. b. glaucoma. c. presbyopia. d. cataract. 2. A specialized instrument that measures hearing acuity at different frequencies is the: a. tuning fork. b. tympanometer. c. audiometer. d. Rinne tester. 3. Which of the following charts are commonly used to assess distance visual acuity in the adult? a. Snellen b. Jaeger c. Ishihara d. Tumbling E 4. Which of the following is an example of a gross hearing test? a. Rinne test b. Audiometry c. Weber test d. Meniere’s test 5. What is the proper way to position the ear when performing an ear instillation in a child under the age of three? a. Up and back b. Down and back c. Up and forward d. Down and forward 6. What chart(s) may be used to determine visual acuity in a preschooler? a. Tumbling E chart b. Landolt C chart c. Allen object recognition chart d. All of the above
Web Activities 1. Search the WebMD Web site (www.webmd.com) and type “eye health” or “ear health” in the search area for multiple topics on each.
2. Go to the American Academy of Ophthalmologists Web site (www.aao.org) and research new procedures being tested or performed to help restore sight. Write a one- to two-page paper describing at least two of these procedures. 3. The National Institute on Deafness and Other Communication Disorders Web site (www.nidcd .nih.gov) provides information on hearing defects. Search for the latest treatments for hearing restoration.
CONNECTION Using your StudyWARE CD-ROM: ❖ Complete the Hangman and Concentration activities for this chapter. ❖ Complete the Quiz for this chapter in Test Mode.
THE DVD LINK On your StudyWARE CD-ROM, go to the DVD Challenge for this chapter. View the DVD clip and respond to the following questions: 1. After watching the medical assistant instill eye ointment into the patient’s eye, why do you think that it is probably best to have the patient remove her eye makeup before instilling the ointment? 2. What is the purpose of placing cotton in the patient’s ear following an ear instillation? What little tip will assist in preventing the cotton from absorbing medication that you place in the patient’s ear?
C H A P T E R
Gastrointestinal Evaluations and Procedures Chapter Outline Types of Providers Who Specialize in Treating GI Disorders Patient Screening for the GI System GI Examinations Performed in the Medical Office Abdominal Pain Rectal Exams and Various Types of Fecal Testing Diagnostic Procedures Screening Colonoscopy
Nutrition Nutritional Guidelines Health Benefits from the Food Groups Educating Patients about Good Nutrition Exercise Eating Disorders
14 Essential Terms anorexia nervosa anoscope bulimia nervosa clostridium difficile colonoscopy defecate discretionary calories fecal occult blood fissure gastroenterologist gastroenterology hemorrhoids hepatologist minerals occult ova and parasite (O&P) parietal pain proctologist proctoscope referred pain sigmoidoscopy stool culture United States Department of Agriculture (USDA) visceral pain vitamins
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KEY COMPETENCIES
CAAHEP
ABHES
Instructing the Patient on How to Collect a Fecal Specimen
III.C.3.b.2.e
VI.A.1.a.4.x
Performing a Fecal Occult Blood Test
III.C.3.b.4.e
VI.A.1.a.4.h
Assisting with a Flexible Sigmoidoscopy
III.C.3.b.4.e
VI.A.1.a.4.x
Developmental Objectives After completing this chapter, you should be able to: 1. Correctly spell and define the essential terms. 2. List and describe nine different procedures that may be performed by the gastroenterologist. 3. List and describe instruments and supplies necessary for basic anal/rectal exams. 4. List and describe the role of the medical assistant in setting the patient up for outside procedures. 5. List and describe four different tests that may be performed on stool. 6. List common instructions given to patients for occult blood studies. 7. Compare and contrast the eating disorders anorexia nervosa and bulimia. 8. Explain the importance of good nutrition as it relates to health issues. 9. List six different sections of the food pyramid and list examples from each group. 10. Explain the role of exercise in a healthy lifestyle. 11. List and describe the different parts of a food label.
Introduction Disorders of the gastrointestinal (GI) system may have a direct relationship to pathology of other body systems. Often during routine examination of the patient, complaints of heartburn, abdominal pain, weight fluctuations, or bowel irregularities arise. Laboratory evaluation may indicate dysfunction of organs within or outside of the GI system. Some tests are noninvasive and can be performed in the office. Testing for blood in the stool is often a role of the medical assistant. Various invasive procedures, such as colonoscopy (a procedure that examines the colon), are used for diagnosis and treatment, requiring preparation and patient education by the medical assistant. These procedures are performed in a hospital or outpatient facility. Other exams, such as pH monitoring or capsule endoscopy, may be performed by the medical assistant within the office setting. Food intake can have a direct impact on the organs within the gastrointestinal tract. Food choices not only influence what happens in the gastrointestinal tract but within the entire body as well and can lead to disease within the body when good nutrition is not instituted. Having a basic understanding of nutrition will help in educating the patient and overall disease prevention and management.
G A S T R OI N T E S T I N A L E VA L U AT I O N S A N D P R O C E D U R E S
TYPES OF PROVIDERS WHO SPECIALIZE IN TREATING GI DISORDERS A physician who specializes in the treatment of gastrointestinal disorders is called a gastroenterologist. A proctologist is a physician who specializes in treating disorders of the lower bowel, rectum, and anus. A hepatologist performs specialized exams to diagnose and treat liver disease. These providers often call upon the services of a dietician (a professional who counsels patients on dietary intake) to assist patients with gastrointestinal or liver disorders. Medical assistants often choose to work in areas of specialty. Being familiar with the information in this chapter will assist those who want to work in GI specialty practices as well as general practice offices.
PATIENT SCREENING FOR THE GI SYSTEM Medical assistants may have the responsibility of screening patients prior to provider examination or over the phone. The depth of screening will be established by office protocol but, in general, medical assistants should be able to ask a series of questions related to the patient’s symptoms. Table 14-1 lists the types of questions that are typically asked during a GI screening and the common procedures that coincide with symptoms.
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FI E L D S M A R T S Remember that thorough preparation and anticipating the needs of a patient will enhance your professional relationships, improve your time management, and provide you with a smoother transition for patient flow within the office.
Important note: Medical assistants should never perform any procedure unless directed to do so by the provider. However, they can set up various equipment and supplies to help save time in the event that testing is ordered.
GI EXAMINATIONS PERFORMED IN THE MEDICAL OFFICE GI exams in the standard family or general practice office will often consist of an external examination of the abdomen and possible examination of the anus and rectum. The provider may send the patient to a hospital or x-ray facility for further testing. When the general practitioner feels that patient’s symptoms are beyond her expertise, the patient may be referred to a GI specialist.
TABLE 14-1 Patient Screening and Instructions for the Digestive System ASK THE PATIENT: “ARE YOU EXPERIENCING ANY. . .”
Nausea or vomiting, diarrhea, constipation, change in bowel habits, black tarry stools, the expulsion of gas, belching, heartburn, difficulty in swallowing, any changes in appetite or weight loss, gastric or abdominal pain, or hemorrhoids? Do you have any history of GI disorders?
DISROBING INSTRUCTIONS
If symptoms appear above the waist, have the patient remove everything except undergarments and put on a gown; if symptoms appear below the waist, have the patient remove underwear and put on a gown.
VITAL SIGNS
Blood pressure, temperature, pain rating
EQUIPMENT
Anoscope/proctoscope (if the patient complains of rectal or anal symptoms) Note: For patient comfort, provide an emesis basin and trash bag if the patient is nauseated or has vomited.
POSSIBLE IN-OFFICE PROCEDURES
Anoscopy or proctoscopy (if symptoms are related to the rectum or anus) Fecal occult blood test (if there is blood in the stool)
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EMR makes sending information to a specialist easy. With a click of the button, the medical assistant can send the referral form, patient’s labs, diagnostic reports, and progress notes to the appointed specialist. To be in compliance with HIPAA guidelines, it is important that the medical assistant send only the information that is absolutely necessary in order for the specialist to diagnose and treat the patient. Before sending electronic records, the medical assistant should make certain that she selected the correct pro-
When the patient is referred to a specialist, the medical assistant will often have the responsibility of gathering the appropriate paperwork, which generally includes any related labs or diagnostic tests previously performed, referral information, and corresponding progress notes. This will assist the specialist in knowing how to proceed and eliminate the redundancy of performing tests that have already been conducted.
Abdominal Pain A common complaint leading to a gastrointestinal examination is stomach or abdominal pain. Three general categories of abdominal pain, which may be determined by patient description during physician examination, include: 1. Visceral pain: Occurs when the hollow organs of the GI tract forcefully contract or distend. The patient may describe this pain as burning, cramping, gnawing, or aching. 2. Parietal pain: Caused by inflammation and aggravated by movement. The patient may describe this pain as constant and severe. 3. Referred pain: A pain felt at a site away from the actual pain site. This pain may radiate or travel. Another reason that a patient may seek the care of a GI specialist may be solely for a screening evaluation when no symptoms are evident, such as a colonoscopy. Many insurance companies now require providers to offer or encourage patients to have screening exams; however, there may be limitations such as how often the test can be performed, or by whom the test may be performed. The medical assistant will need to check this information prior to setting up the procedure.
vider and e-mail address. There should always be a confidentiality notice attached to the e-mail in the event the record is received by someone other than the intended recipient. Providers on the receiving end should send a confirmation e-mail back to the referring office stating that they received the information and thank the referring provider for the referral. If the referring practice does not receive a confirmation e-mail, a follow-up phone call should be made to the receiving practice.
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SITE CHECK As a site reviewer, I will check to make certain that the practice keeps up with preventive health maintenance standards by offering or encouraging patients to have routine health maintenance testing. Colonoscopy is one such screening exam. Reviewing the patient’s record when the patient is in for a current visit and reminding the provider when the patient is due for these screenings will assist the practice in meeting health prevention goals and will help to keep the patient healthy for as long as possible.
Rectal Exams and Various Types of Fecal Testing The provider will typically perform an exam of the rectum when the patient complains of rectal bleeding or pain. The provider will palpate the anus and rectum for any tenderness, nodules, or other irregularities. The medical assistant should prepare the following equipment and supplies for the exam: anoscope, an instrument to examine the anus (Figure 14-1), or proctoscope, an instrument to examine both the anus and rectum (Figure 14-2), occult blood testing supplies (used in a test that checks for hidden blood in the stool), lubricant, gloves, and tissues.
G A S T R OI N T E S T I N A L E VA L U AT I O N S A N D P R O C E D U R E S
Hirschman anoscope
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Typical positions used during rectal exams include the following: ❖ Sims’ position or left lateral position ❖ Lithotomy position ❖ A standing position with the patient bent over the exam table
FIGURE 14-1 An example of an anoscope used to examine the anus Hirschman proctoscope
FIGURE 14-2 An example of a proctoscope used to examine both the anus and rectum
Patients should not be positioned until just prior to the examination and should be draped for modesty and comfort. The room should be well-lit and at a comfortable temperature. A fecal specimen obtained during the examination is generally tested to see if any blood is present. Often, patients are unaware that they have blood in their stool because it is hidden. The medical term used to describe the word hidden is occult. Hidden blood in the stool is referred to as fecal occult blood. Blood in the stool can be indicative of different pathological conditions including hemorrhoids (swollen blood vessels in and around the anus and lower rectum that stretch under pressure), fissures (cracks in the anal skin usually caused by hard bowel movements), or other more serious conditions such as ulcers or cancer in the gastrointestinal tract. Patients may be requested to gather additional specimens in their home. Good instructions are very important when educating patients about collecting inhome specimens. The patient must have a thorough understanding of special dietary requirements, collection requirements, and proper instructions for sending back the specimens. Refer to the Patient Tutor tool box on this page. Refer to Procedure 14-1 for a list of steps and rationale for testing for occult blood in the patient’s stool.
When providing patients with fecal occult blood testing supplies, it is important to supply verbal and written instructions for the highest level of compliance. General instructions may include the following: ❖ Avoid taking nonsteroidal anti-inflammatories (NSAIDs) for seven days prior to and during testing. ❖ Avoid taking more than 250 mg per day of vitamin C for three days prior to and during testing.
❖ Avoid red meat, raw vegetables, fruits, and rectal suppositories at least three days prior to and during testing. Samples of what to eat may include: well-cooked pork, poultry, fish, cooked vegetables and fruit, and foods high in fiber. ❖ Complete the blanks on the front of the test cards prior to testing. This is for sanitary purposes. ❖ Select samples from three different days. ❖ Make certain that you follow collection instructions supplied with test kit.
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Following examination of the patient, the provider may also want the patient to collect other stool samples for various types of testing including: ❖ Stool culture: A test that looks for various types of bacteria or other microorganisms that may be contributing to the patient’s symptoms. ❖ Clostridium difficile or “C-Diff” testing: The proliferation of this microorganism causes a condition known as pseudomembranous colitis, an uncontrollable diarrhea. This condition is often the result of antibiotic therapy. ❖ Ova and parasite (O&P) testing: Testing that is performed to identify intestinal parasites and their eggs or cysts in patients with symptoms of gastrointestinal infection. The patient is instructed to defecate (pass stool) into a special collection container and to transfer the specimen into the appropriate containers. Collection and preservation instructions should be in writing and reviewed with the patient prior to leaving the office. Refer to Procedure 14-2 for specific instructions on proper collection of a fecal specimen.
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CR ITI C A L TH I N K I N G C H AL LEN G E A patient calls the office to state that she has had continuous diarrhea since her last appointment when she was diagnosed with a bacterial infection and placed on antibiotic therapy. The patient wants to know if the provider can call something in for her diarrhea. 1. What may be causing the excessive diarrhea? 2. Should you share your suspicions with the patient? 3. Are you allowed to diagnose the patient? 4. Why is it unlikely that the provider will have you call in a prescription for the patient’s diarrhea? 5. Based on the patient’s symptoms, should she be offered an appointment?
DIAGNOSTIC PROCEDURES There are certain diagnostic procedures that are specific to the field of gastroenterology. Many of these procedures require special patient preparation that must be followed to the letter. Preparation for most GI procedures includes fasting and total cleansing of the bowel. It is important to follow the protocol for patient preparation that is mandated by the facility where the procedure will be performed. Fully explain all preparation instructions to patients and give them a printed copy of the instructions to take home with them. In general, any examination of the lower colon will incorporate a combination of dietary restrictions and bowel elimination procedures through the use of laxatives and enemas. Examinations of the upper colon do not usually involve bowel cleansing procedures but may involve dietary restrictions. Table 14-2 lists some of the diagnostic procedures that are particular to the field of gastroenterology.
Screening Colonoscopy Overview Colorectal cancer is the third most common cancer diagnosed in both men and women, with a projected increase in the next several years, according to the American Cancer Society (ACS). The purpose of screening using a colonoscope is to find polyps and cancers before symptoms of cancer are evident. A family history of colorectal cancer increases the patient’s chance of developing this cancer.
Risk Factors Associated with Colorectal Cancer ❖ Family history of colorectal cancer ❖ Ethnicity; Eastern European Jews have a higher incidence ❖ Personal history of colorectal cancer ❖ History of intestinal polyps ❖ Inflammatory bowel disease; ulcerative colitis or Crohn’s disease ❖ Increased age ❖ High-fat diet ❖ Inactivity ❖ Diabetes; 30% increased chance of colon cancer ❖ Smoking; 30% to 40% higher incidence of developing colorectal cancer ❖ Heavy alcohol usage
Recommendations for Early Colorectal Detection Patients with average risk, age 50 or older, should have one of the options listed below:
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TABLE 14-2 Gastroenterology Diagnostic Procedures PROCEDURE
DESCRIPTION
Sigmoidoscopy
The lower portion of the colon is viewed using a flexible lighted scope most commonly used to evaluate GI bleeding or diarrhea.
Capsule endoscopy
A video camera is placed inside a capsule that the patient swallows. As the capsule tumbles through the small intestine, video images are recorded and analyzed via a computer. This is useful in diagnosing Crohn’s disease, ulcers, and colon cancer.
24-hour pH monitoring
A probe is placed through the patient’s nose down to the distal esophagus and left in place for 24 hours. The probe is attached to a small recorder and continuous pH values are obtained. This is useful in diagnosing acid reflux.
Hydrogen breath test
The patient ingests a standard dose of lactose followed by the measurement of exhaled hydrogen. An increase in the hydrogen exhalation by 20 ppm (parts per million) indicates lactose intolerance.
Procedures requiring patient sedation:
1. 2. 3. 4.
Colonoscopy
The entire colon is examined with a flexible lighted videoscope. Polyps and other growths can be removed during the procedure.
Esophagogastroduodenoscopy (EGD)
The esophagus, stomach, and first portion of the small intestine (duodenum) are examined with a videoscope.
Endoscopic retrograde cholangiopancreatography (ERCP)
A videoscope is placed near the opening of the common bile duct and pancreatic duct followed by the use of catheters to access the appropriate duct. Incisions can be made through the scope and stones may be extracted with balloons or baskets.
Enteroscopy
A long videoscope called an enteroscope is used to examine the distal duodenum and jejunum.
Endoscopic ultrasound
A videoscope with an ultrasound device at the tip of the scope allows the source of the ultrasound to be placed close to the lesion or growth, which provides a better image.
Fecal occult blood test annually Flexible sigmoidoscopy every five years Double contrast barium enema every five years Colonoscopy every 10 years following the initial screening procedure
Patients with strong risk factors should evaluate their recall time with their provider. Those with polyps may repeat colonoscopy screenings every one to six years depending on the size and number of the polyps.
Preparing and Educating the Patient for the Procedure. Instruction should include related procedural terms and an explanation of the procedure itself along with the patient’s responsibility for a successful procedure.
❖ A colonoscope is a flexible lighted viewing scope with a camera that is inserted into the patient’s rectum. It is attached to a video display, allowing the provider to view the lining of the colon. ❖ A polyp is an abnormal growth extending from the interior of the colon. The polyp can be removed during the colonoscopy to be evaluated by a pathologist. ❖ The patient will have an IV and will be sedated. The patient will be awake, but probably will not recall any portion of the test. ❖ The patient will need transportation from the facility. The patient will not be able to drive. ❖ Preprocedurally, the patient will have the following responsibilities to thoroughly clean the bowel:
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❖ The day before the exam only clear fluids will be ingested. Nothing red, orange, or purple will be allowed. ❖ No dairy products or alcoholic beverages should be consumed the day prior to the exam. ❖ Various forms of laxatives, depending on the patient and prescribed by the physician, will be taken based on a prescribed schedule. ❖ Aspirin or aspirin-like products will be discontinued for five days prior to the procedure. This also includes NSAIDs. Tylenol is a safe alternative. ❖ Avoid vitamin E if possible. ❖ No blood thinners, such as coumadin and Plavix, should be taken for a predetermined number of days prior to the exam. ❖ Iron preparations will be discontinued for a prescribed time prior to the test. ❖ Foods with seeds or nuts should be avoided. ❖ Nothing by mouth after midnight prior to the exam. Resources include www.cancer.org (American Cancer Society) and www.nim.nih.gov/medlineplus.
NUTRITION As people, both adults and children, throughout the world have become increasingly more overweight, obesity has reached epidemic proportions. Public health studies suggest that approximately 31% of adults and 15% of children and teenagers are obese. Nutrition not
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F IEL D S M A R T S Vitamins are organic substances in the diet that are found in plants and animals and are necessary for normal growth and development. There are two types of vitamins: fat soluble, which includes A, D, E, and K, and water soluble, which includes the B complex and C vitamins. Minerals are inorganic elements that are essential for normal body function and include elements such as sodium, potassium, and magnesium. Vitamins and minerals can interact with particular medications, so always get a complete list from the patient when obtaining a medication history.
only plays a big role in a person’s weight but overall health as well. Poor food choices may contribute to conditions such as heart disease, diabetes, and colon cancer. Health care professionals have a responsibility to educate patients about the importance of good nutrition.
Nutritional Guidelines New nutritional guidelines have been developed, revising and improving upon the original concept of the “Basic Four.” The latest nutritional guidelines from the United States Department of Agriculture (USDA) conclude that “One Size Doesn’t Fit All,” which makes a great deal of sense when thinking about the fact that people come in all different sizes and ages and have a wide array of different activity levels. An interactive Web site, www.mypyramid.gov, has a wealth of information related to food and nutrition and encourages participants to build their own food pyramids. Participants just go to the MyPyramid Web site and answer a list of questions regarding gender, age, and activity levels. After entering the pertinent information, a food pyramid is designed matching the participant’s specifications. The Web site has a host of other activities as well and will even track the participant’s diet over a full year to provide the participant with continuous feedback in an attempt to improve dietary choices. This is a great Web site for patients. Table 14-3 color-correlates with the food pyramid shown in Figure 14-3 and provides information regarding the 2006 nutritional guidelines.
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FI E L D S M A R T S The new food pyramid includes a category referred to as discretionary calories. This category refers to items that have little nutritional value but add calories to the diet. They are also referred to as “extras” and include items such as salad dressings, sweetened cereals, higher-fat meats, bakery items, oils, and alcohol. Only a small fraction of consumed calories should come from this category. The number of discretionary calories that an individual can take in and still maintain good health is based on the individual’s age, sex, and activity level, but usually falls somewhere between 100 to 300 calories per day.
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TABLE 14-3 USDA Nutritional Recommendations and Guidelines FOOD GROUP
GENERAL RECOMMENDATIONS
EXAMPLES
CAUTION/AVOID
Grains
At least 3 ounces of grain sources should come from whole grain cereals, breads, crackers, rice, or pasta.
Whole grain bread Crackers Rice Pasta
White flour White bread White rice Spaghetti Macaroni
Vegetables
Increase intake of green and orange vegetables, dry beans, and peas.
Broccoli, collard greens, spinach, bok choy, romaine lettuce Carrots, sweet potatoes, pumpkin, squash (acorn, hubbard, and butternut) Tofu, black beans, black-eyed peas, lentils, kidney beans, soy beans
Starchy vegetables such as corn and white potatoes
Fruits
Have a wide variety of fruits, including fresh, frozen, canned, or dried. Servings will vary according to age group.
Apples, bananas, berries (blackberries, strawberries, cherries, raspberries), grapes, melons, oranges
Use caution when ingesting fruit juices; 100% fruit juice is recommended. Processed fruit juices
Oils
Limit oils to balance total calorie intake.
Fats obtained from nuts, fish, and vegetable oils Oils made with polyunsaturated fatty acids (PUFA) or monounsaturated fatty acids (MUFA), such as canola, corn, cottonseed, olive, safflower, soybean, or sunflower
Butter Shortening Stick margarine Beef, chicken, or pork fat Trans fats
Milk and dairy products
Select products that are fat-free or low in fat when choosing milk, cheese, yogurt, and other dairy products.
Low-fat: milk, cheese, yogurt, pudding, ice cream, frozen yogurt Note: If lactose intolerant, choose lactose-free products such as hard cheeses and yogurt.
Whole milk High-fat dairy products
Meat and beans
Select meats that are lower in fat such as pork or chicken. Prepare meats by grilling, broiling, or roasting. Vary choices.
Lean meats: beef, pork, bison, giblets Poultry: chicken, turkey, goose, duck Fish: catfish, cod, snapper, clams, crab, herring, lobster, salmon, squid, trout Note: Bake, broil, or grill selections. Nuts Dry beans
Fatty meats Organ meats Skin on chicken or turkey
Amounts will vary according to the individual.
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FIGURE 14-3 The new food pyramid can be personalized for each individual by entering personal statistics into the MyPyramid.gov Web site. This example shows an 1,800 calorie food pattern for a 23-year-old female, 5 feet 3 inches tall, 118 pounds, physically active less than 30 minutes a day.
Grains
6 ounces
Vegetables
2.5 cups
Fruits
1.5 cups
Milk and Dairy
Meat and Beans
Health Benefits from the Food Groups There are many health benefits that can be gained from the various food groups such as reducing the risk of coronary artery disease, stroke, type 2 diabetes, and osteoporosis, to name a few. Table 14-4 lists the different food groups and some of the health benefits of consuming foods from each group.
Educating Patients about Good Nutrition Food diaries supply providers with important data regarding the patient’s nutritional intake. Patients are asked to record everything they eat for a prescribed number of days. The provider will review the diary and check to see if the patient is taking in an adequate number of calories and getting all of the nutrients that are essential to good health. The provider will then design a dietary program (which often includes exercise) that will correlate with predetermined goals, such as weightloss management, disease management, or overall health
3 cups
5 ounces
maintenance. After instituting a plan of action, the food diary should be reviewed periodically for feedback. Another area of patient education related to nutrition is the patient’s ability to evaluate food labels (Figure 14-4). Marketing tools are often misleading and the patient must be prepared to review the labels of the food being purchased. Often times, providers do not feel qualified to counsel patients dietetically and will send patients to a licensed dietician or nutritionist. This is particularly common with patients who have diabetes or heart disease, or for those who struggle with obesity. It is often the medical assistant’s duty to schedule the patient with a dietician. This usually has to be preapproved with the insurance company in order for the services to be covered. The medical assistant may be responsible for any or all of the following: ❖ Obtaining a preauthorization from the insurance company.
Patients should be educated on how to properly read a food label. Food labels such as the one in Figure 14-4 list all the information required by law on each product. The U.S. Food and Drug Administration recommends that individuals pay close attention to the following sections of a food label: 1. Serving size and the number of calories per serving—many people think that a serving size is the whole container. 2. Limited nutrients including total fat, both saturated and trans fats, cholesterol, and sodium.
3. The number of carbohydrates, fiber, sugars, and proteins in the product. 4. Individual list of nutrients that include vitamins. 5. Footnotes that list the % Daily Value of key nutrients. Patients may refer to the FDA’s Web site for further information (www.cfsan.fda.gov).
TOOL BOX
PAT I E N T T U T O R
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TABLE 14-4 Health Benefits of the Various Food Groups FOOD GROUP
HEALTH BENEFIT
Grains
High in fiber and help to reduce the risk of coronary disease. Increased fiber may reduce constipation. Whole grains help with weight management. Vitamins and minerals found in particular grains and their functions: Folate: Important in forming red blood cells. Iron: Transports oxygen in the blood. Magnesium: Assists in building bones.
Fruits and vegetables
Diets rich in fruits and vegetables may help to reduce the risk of stroke. Diets rich in fruits and vegetables may help to reduce the risks of type 2 diabetes. Diets rich in fruits and vegetables may help to prevent various types of cancer including rectal, colon, stomach, and mouth cancer. Fruits and vegetables are low in fat and calories and contain no cholesterol. Fruits and vegetables contain fiber, which aids in relieving constipation. Vitamins and minerals found in particular fruits and vegetables and their functions: Potassium: Helps maintain blood pressure. Vitamin A: Important in eye health. Vitamin C: Important in wound healing and assists with iron absorption.
Milk and dairy products
Build and maintain bone mass, therefore reducing risk of osteoporosis. Vitamins and minerals found in particular milk and dairy products and their functions: Calcium: Helps build strong bones and teeth. Potassium: Helps maintain blood pressure. Vitamin D: Helps maintain proper blood levels of calcium and phosphorus.
Meat and beans
Great sources of protein, which helps build bones, muscles, cartilage, skin, and blood. Vitamins and minerals found in meats and beans and their functions: B vitamins: Important for energy and assist in the formation of red blood cells. Vitamin E: An antioxidant (studies suggest that antioxidants may help to prevent certain types of cancer from forming). Magnesium: Important in building bones. Omega-3 fatty acids: Help reduce the risk of cardiovascular disease. Heme-iron: Important in preventing iron deficiency anemia.
Oils
Polyunsaturated fats contain essential fatty acids that are necessary for every cell in the body. Fats are needed to process fat-soluble vitamins, A, D, E, and K. Vitamins and minerals found in oils and their functions: Vitamin E: Assists with immunity and is considered an antioxidant (studies suggest that antioxidants may help to prevent certain types of cancer from forming).
Source: Mypyramid.gov.
❖ Sending the pertinent records to both the insurance company and dietician. ❖ Scheduling the appointment. The medical assistant may need to follow up with the patient to make certain that the patient followed through with the appointment.
EXERCISE As obesity approaches epidemic numbers, the awareness of physical activity requirements in conjunction with better nutrition has risen. Some studies suggest that as many as 60% of American adults do not participate in enough physical activity, and 25% receive no
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Nutrition Facts Serving Size: 1/2 Cup Servings Per Container: 4 Amount Per Serving Calories 100 Calories from Fat 30 % Daily Value* Total Fat 3g 5% Saturated Fat 0g 0% Trans Fat 0g Cholesterol 0mg 0% Sodium 340mg 14% Total Carbohydrate 15g 5% Dietary Fiber 1g 4% Sugars 0g Protein 2g Vitamin A 0% • Vitamin C 0% Calcium 0% • Iron 2% *Percent Daily Values are based on a 2,000 calorie diet. Your daily values may be higher or lower depending on your calorie needs: Calories
FIGURE 14-4 The food label provides valuable information about the ingredients contained within a product, the amounts per serving, vitamin content, and caloric content.
2,000
2,500
Total Fat Less than 65g 80g Sat Fat Less than 20g 25g Cholesterol Less than 300mg 300mg Sodium Less than 2,400mg 2,400mg Total Carbohydrate 300g 375g Dietary Fiber 25g 30g
Calories per gram: Fat 9 • Carbohydrate 4 • Protein 4 Ingredients: Flour, Water, Yeast, Vegetable Oil, Salt, Artificial Flavor and Color.
exercise at all. A healthy lifestyle is contingent upon an acceptable level of activity, whether for weight loss or treatment of a health disorder. As people become more sedentary, there is an increase in obesity and chronic disease including coronary disease, hypertension, type 2 diabetes, cancer, osteoporosis, depression, and anxiety. Some important guidelines and recommendations for physical activity include: ❖ Before partaking in any increased level of activity or beginning a new exercise program, obtain a physical examination. ❖ Adults should attempt to engage in at least 30 minutes of moderate activity (over normal daily activity) each day. A longer duration would be more beneficial. ❖ Prevention of weight gain may require 60 minutes of activity per day. ❖ Weight loss may require 60 to 90 minutes of moderate activity on most days.
❖ Alter the workout plan to prevent boredom. ❖ Include cardiovascular conditioning for cardiovascular health. ❖ Include stretching exercises to improve or maintain flexibility. ❖ Incorporate resistance exercises or calisthenics to improve strength and endurance. ❖ Children and adolescents should participate in at least 60 minutes of physical activity every day if possible. ❖ Pregnant women, if physically cleared, should engage in 30 minutes of activity on most days. The activities should be designed to avoid falls or contact with the abdominal region. Regular exercise does not affect the ability to breastfeed. ❖ Older adults should continue to exercise as tolerated. This may slow the functional declines related to aging. ❖ Greater benefits may be achieved with a more strenuous workout or one for an extended period of time. Adjusting the requirements for caloric intake and exercise can be assessed by using BMI and waist circumference measurements. These are discussed in Chapter 11.
EATING DISORDERS Severe changes in eating patterns or eating behavior is characteristic of an eating disorder. Many times, the person with this type of disorder is an overachieving female. Classifications of the disorders are as follows: ❖ Anorexia nervosa: Characterized by a drastic reduction of food intake in an effort to minimize body weight. Any weight gain is perceived negatively. This disorder is primarily seen in adolescents but can also occur in adulthood. Medical and psychological support is essential in the treatment of this disorder. ❖ Bulimia nervosa: Involves a dangerous pattern of eating that includes binging followed by purging. The purge may be by vomiting, using laxatives, diuretics, or diet pills, or through excessive exercise. Any method of ridding the body of the excess food intake may be attempted. ❖ Compulsive overeating: Characterized by excessive (binge) eating followed by depression related to the food. The eating pattern is used to relieve stress or depression, but in turn, causes it to increase.
G A S T R OI N T E S T I N A L E VA L U AT I O N S A N D P R O C E D U R E S
❖ Night eating syndrome: Occurs when patients are awakened by hunger throughout the night. Binging occurs during the late hours, causing the person to not be hungry in the morning hours. All four types of eating disorders have been linked to psychological and physical causes. Therefore, both areas
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must be addressed for treatment. Failure to resolve the disorder will prove hazardous to the patient’s health, and can be fatal. Due to the high incidence in the adolescent years, discussions of anorexia and bulimia are included in Chapter 17.
PROCEDURE 14-1 Perform a Fecal Occult Blood Test Objective: To instruct a patient how to properly prepare for fecal occult blood testing; how to collect the sample for testing; and how to accurately perform the testing once the sample has been collected.
Equipment/Supplies: ❖ Gloves ❖ Test cards and developer ❖ Return envelope
❖ Patient record/pen ❖ Home care instruction form
PROCEDURAL STEPS
RATIONALE
1. Assemble the supplies.
Having all the supplies at hand saves time. An expired test kit can give an inaccurate result.
2. Identify the patient using two identifiers and identify yourself.
Using two identifiers will help to ascertain that you have the correct patient.
3. Explain the purpose of the procedure.
Proper preparation and collection by the patient assures accurate results.
4. Explain special dietary instructions that the patient is to follow prior to collecting the specimen.
Certain medications and foods may interfere with test results, giving either a false positive or false negative.
5. Explain how to properly label the cards prior to testing.
Having the patient label the cards prior to testing will keep the patient from contaminating the hands following the procedure.
6. Explain instructions for collecting the samples, including how many samples the patient is to collect.
The patient must understand how to properly collect the samples to ensure test accuracy.
7. Explain the instructions for sending the samples back to the office. 8. Once the test cards are received in the office, wash your hands and apply gloves before testing begins.
Standard precautions must be practiced when completing tests on all human samples. continues
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continued
PROCEDURAL STEPS 9. Correctly follow the developing instructions, including performing a control on each test (Figure 14-5). A blue color indicates a positive result (Figure 14-6).
RATIONALE The instructions must be followed exactly and correct timing is crucial for accurate results. Performing controls ensures that the testing cards and developer are working correctly.
10. Properly dispose of the test cards and clean the work area.
Proper disposal is essential to prevent cross-contamination.
11. Remove gloves and wash your hands.
Helps to reduce the risk of contamination.
12. Document the procedure and results in the patient record.
Accurate charting is essential to ensure proper patient care.
DOCUMENTATION EXAMPLES:
12-13-XX 9:45 a.m.
Hemawipe testing instructions per Dr. Jones. Pt. supplied with testing cards and spatulas to obtain three test samples at home. Verbal and written preparation and collection instructions given. Pt. expressed understanding of procedure and will mail test cards to office in enclosed mailer. Judith Jones, CMA (AAMA)
12-20-XX 10:30 a.m.
Hemawipe test cards received in office today. Test completed. Results: negative (–) for all three specimens. Judith Jones, CMA (AAMA)
FIGURE 14-5 Hold the developing
FIGURE 14-6 A blue color indi-
solution over the card and apply the correct amount of drops to the test and control sections.
cates a positive test result and no color change indicates a negative test result.
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PROCEDURE 14-2 Instruct the Patient on How to Collect a Fecal Specimen Objective: To instruct a patient on the proper way to collect and preserve a fecal specimen.
Equipment/Supplies: ❖ Laboratory request form ❖ Specimen container with a lid ❖ Specimen container label
❖ Tongue depressors ❖ Printed instructions ❖ Patient record
PROCEDURAL STEPS
RATIONALE
1. Assemble all the equipment.
Assembling the equipment ahead of time eliminates interruptions in the teaching process.
2. Identify the patient using two identifiers and identify yourself.
Using two identifiers will help to ascertain that you have the correct patient.
3. Explain the provider’s orders.
Explaining the orders will help the patient to comprehend the instructions.
4. Fill out the laboratory request form and specimen label with all pertinent patient information and affix label to the specimen container (Figure 14-7).
An incomplete laboratory request form or specimen label can delay testing.
5. Instruct the patient to use the tongue depressors to collect a small portion (approximately 3 to 4 tablespoons full) of the next bowel movement and place it in the specimen container. Stress the importance of not contaminating the specimen with urine, toilet tissue, or any other foreign material.
If the specimen is contaminated with any foreign material, it may not be suitable for testing and the results could be inaccurate.
6. Instruct the patient to place the lid tightly onto the specimen container and to write the time and date the specimen was collected on the specimen label. Stress the importance of returning the specimen to the office or laboratory as soon as possible. The specimen may be refrigerated if it cannot be taken to the lab within two hours of collection.
A tight-fitting lid and refrigeration decreases bacterial growth in the specimen.
7. Provide the patient with a copy of the printed instructions.
Printed instructions that the patient can take home will help the patient to remember the proper steps for collecting the specimen.
Room CONTENTS Patient Doctor Date
FIGURE 14-7 An example of a stool specimen container with an identifying label attached to the lid
8. Document the procedure in the patient record.
DOCUMENTATION EXAMPLE:
10-10-XX 10:30 a.m.
Sex
Instructed pt. on proper method of collecting a fecal sample per Dr. Leonard’s orders. Provided pt. with printed instructions. Kate Lilly, RMA
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PROCEDURE 14-3 Assist with a Flexible Sigmoidoscopy Objective: To assist the provider with a flexible sigmoidoscopy by ensuring the function of the equipment, preparing the patient, assisting during the procedure, and sterilizing the equipment after the procedure.
Equipment/Supplies: ❖ ❖ ❖ ❖ ❖
Disposable gloves Sterile specimen container Flexible sigmoidoscope Lubricant Biopsy forceps
PROCEDURAL STEPS
❖ ❖ ❖ ❖
Light source Tissue Gown and drape Patient record/pen
RATIONALE
1. Wash hands and apply gloves.
Handwashing is the principle method of preventing the spread of infection.
2. Assemble the equipment. Ensure that all is in acceptable working condition (Figure 14-8).
Having all equipment and supplies ready will save time.
3. Identify the patient using two identifiers and identify yourself. Explain the procedure. Label the sterile specimen container with all pertinent patient information.
Identifying the patient provides insurance that the procedure and examination performed is on the correct patient. Explaining the procedure increases compliance and patient comfort.
FIGURE 14-8 The medical assistant checks the flexible sigmoidoscope to be sure it is ready for the procedure.
4. Allow the patient to use the restroom.
Emptying the bladder will allow for a more comfortable procedure.
5. Supply the patient with a gown, instructing the patient to disrobe below the waist and place the gown with the opening in the back. Provide a drape for added privacy.
This allows for the most privacy possible during a sigmoidoscopy.
6. Assist the patient into the Sims’ position. Place the drape with a corner covering the anal region.
This is the position of choice for the procedure. The draping technique allows for only a minimal portion of the drape to be moved for the procedure. This allows for the most privacy.
7. Provide the physican with suitable disposable gloves. When gloved, provide lubrication to the first digit for rectal examination.
Lubrication makes insertion easier.
8. Lubricate the end of the flexible scope.
Lubrication makes insertion of the scope into the anus easier.
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RATIONALE
9. Be prepared for any requests by the provider. Assist with suctioning during the procedure. 10. Supply biopsy forceps to the provider, if requested. Be certain the specimen container is maintained in a functional position. Place the biopsy specimen into the sterile container.
The specimen is placed in a sterile container to maintain the integrity of the specimen.
11. Following completion of the procedure, provide tissue to the patient to remove any excess lubrication from the anal region. 12. Assist the patient into a sitting position and instruct the patient to remain sitting while you assess the patient’s status.
The patient may become dizzy if allowed to stand up too soon.
13. Once the patient is stable, assist with dressing, if requested. 14. Prepare the specimen for transport to the laboratory. Be certain lab requests are filled out in their entirety.
An incomplete lab requisition could delay testing.
15. Clean the equipment and examination room. Follow the manufacturer’s instructions for cleaning the scope.
Each scope is different and each manufacturer has its own set of cleaning and maintenance instructions.
16. Document the exam and procedure in the patient record.
DOCUMENTATION EXAMPLE:
11-14-XX 10:30 a.m.
Assisted physician with flex sig, Bx obtained and sent to lab. Pt. tolerated well, f/u appt. given. Instructed pt. to contact office with any c/o discomfort. Diet reviewed as requested by physician. Dispensed 4 Sample packs of Nexium (20 mg) per Dr. Davis. Malcolm Jones, RMA
Chapter Summary As evidenced in the text, gastroenterology is a highly specialized field of medicine. Many of the procedures and diagnostic tests are only performed in this type of practice. Keep in mind that this specialty deals with some delicate issues and be aware of the patient’s feelings when dealing with health issues related to this body system. This specialty also deals with various patient education issues; some are complicated and require a thorough explanation by the medical assistant. A lack in patient understanding can lead to poor testing or the inability to perform the test. Because nutrition impacts the gastrointestinal system and the body in general, medical assistants should have a basic understanding of nutritional guidelines and be able to appropriately share that knowledge with the patient.
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FIELD APPLICATION CHALLENGE A 65-year-old female is referred to the office for a screening colonoscopy. She wants to come in and talk about it first. The patient is very anxious because her sister died two years earlier of colon cancer. 1. What other risk factors would indicate the need for a colonoscopy?
2. Is she due for a screening colonoscopy? 3. What instructions would you supply the patient to prepare her for the procedure? 4. What techniques might you employ to help calm the patient?
Chapter Assessment 1. A reason for performing a fecal occult blood assessment is: a. to determine if the patient can follow directions. b. colorectal screening. c. isolating a sexually transmitted disease. d. to determine if the patient can tolerate an EGD.
6. Examination of the entire colon with a flexible lighted video scope is referred to as a(n): a. sigmoidoscopy. b. colonoscopy. c. occult blood test. d. cholangiogram.
2. Which of the eating disorders is characterized by excessive binging followed by depression about food? a. Bulimia b. Anorexia nervosa c. Compulsive overeating d. Both a and c
7. Prior to occult blood studies, patients should be advised to avoid which of the following? a. Red meat b. NSAIDs c. Raw vegetables d. All of the above
3. Discretionary calories are to be used for: a. more fruits. b. more vegetables. c. “extras.” d. more protein. 4. All of the following foods would be included in the meats and beans group except: a. fish. b. peanuts. c. red meat. d. goat cheese. 5. All of the following are considered bad fats or oils except those found in: a. butter. b. margarine or stick butter. c. trans fats. d. olive oil.
Web Activities 1. Review www.radarprograms.com for in-depth information regarding eating disorders. Be aware of characteristics related to the different syndromes. Consider what signs you might look for in your patients. 2. Search www.webmd.com for different disorders that might be observed in the medical office. Remain current with any treatment regimens. Focus on GERD and IBS. 3. Visit the Web site for the American Cancer Society to remain current on the recommendations for colonoscopy. Be able to list the risk factors suggesting the need for the procedure.
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THE DVD LINK
CONNECTION Using your StudyWARE CD-ROM: ❖ Complete the Flash Cards activity for this chapter. ❖ Complete the Quiz for this chapter in Test Mode.
On your StudyWARE CD-ROM, go to the DVD Challenge for this chapter. View the DVD clip and respond to the following questions: 1. When collecting a stool sample for testing, does the patient defecate directly into the specimen container? 2. If the patient is unable to drop the stool specimen off within two hours of testing, what should the patient do with the sample? 3. What instructions did the medical assistant go over with the patient in regards to the preparation instructions for the hemoccult testing? 4. How many windows for each specimen does the patient have to apply a sample to on the hemoccult stool testing card? 5. How many different specimens altogether does the patient have to collect for hemoccult testing? 6. What color does the specimen turn after adding developer if the test is positive?
C H A P T E R
Cardiovascular Exams and Procedures Chapter Outline Types of Providers Who Specialize in Treating Cardiovascular System Diseases and Disorders Patient Screening for the Cardiovascular System Anatomy of the Heart The Heart’s Electrical Conduction System The Cardiac Cycle Types of EKG Units Single-Channel EKG Unit Multichannel EKG Unit Automated EKG Units Telephone Transmission Facsimile EKG Equipment and Supplies EKG Paper Electrodes and Electrolyte Care and Maintenance EKG Lead Placement Standard Limb Leads Augmented Leads
Chest or Precordial Leads Lead Marking Codes Rhythm Strip Standardizing the EKG Performing the Resting 12-Lead EKG Mounting the EKG Tracing Artifacts Cardiac Arrhythmias Premature Atrial Contractions Paroxysmal Atrial Tachycardia Atrial Fibrillation Premature Ventricular Contractions Defibrillation Miscellaneous Cardiac Diagnostic Testing Holter Monitor Treadmill Stress Test Dobutamine Stress Test Echocardiography Cardiac Catheterization Noninvasive Heart Scan
15 Essential Terms amplifier amplitude arrhythmia artifacts atrial fibrillation augmented leads baseline bipolar leads bradycardia cardiac catheterization cardiac cycle cardiologist cardiovascular surgeon cardioversion conduction system defibrillation defibrillator depolarization electrocardiogram (EKG or ECG) electrocardiograph electrodes electrolyte galvanometer Holter monitor continues
C A R D I O VA S C U L A R E X A M S A N D P R O C E D U R E S
KEY COMPETENCIES
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CAAHEP
ABHES
Performing a Standard 12-Lead Electrocardiogram
III.C.3.b.3.a
VI.A.1.a.4.dd
Applying a Holter Monitor
III.C.3.b.4.f
VI.A.1.a.4.b
ischemia isoelectric leads mounting myocardial infarction normal sinus rhythm paroxysmal atrial tachycardia (PAT) precordial leads premature atrial contractions (PACs) premature ventricular contractions (PVCs) repolarization rhythm strip standardization stylus tachycardia wandering baseline waves unipolar ventricular fibrillation (V-fib) ventricular tachycardia (V-tach)
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Developmental Objectives After completing this chapter, you should be able to: 1. Correctly spell and define the essential terms. 2. Trace the circulation of blood through the heart. 3. Describe the heart’s electrical conduction system. 4. Label each wave of the EKG cycle and describe the heart’s action during each phase of the cardiac cycle. 5. Describe the different types of EKG machines. 6. Describe the physical makeup of EKG paper, and state the functions of electrolyte and electrodes. 7. List the 12 leads of an EKG and their marking codes, and describe voltage paths for the limb and augmented leads. 8. Describe the significance of standardizing the EKG. 9. Identify common artifacts found on the EKG tracing and list steps to correct them. 10. List and identify common cardiac arrhythmias. 11. Define defibrillation. 12. Briefly describe the miscellaneous cardiac diagnostic tests discussed in this chapter. 13. State the purpose of Holter monitor application.
Introduction Coronary heart disease is the nation’s single leading cause of death. According to the American Heart Association, approximately 325,000 coronary heart disease deaths occur out-of-hospital or in hospital emergency departments annually. Additional information from the National Health and Nutrition Examination Survey (1999–2004) estimates that 70 million adults age 20 and over have hypertension or high blood pressure. With these kinds of statistics, the need for cardiac education and cardiac screenings is essential. The electrocardiogram (EKG or ECG) is a safe, noninvasive, and painless diagnostic tool that can be quickly and easily performed in the provider’s office. It provides valuable information concerning the patient’s heart health as it measures the amount of electrical activity produced by the heart and the time required for the impulses to travel through the heart with each heartbeat. Although the EKG cannot predict a future myocardial infarction (heart attack), it can detect damage caused by a previous event and by ischemia or a temporary lack of blood flow to the heart. An EKG can also evaluate cardiac arrhythmias (abnormal heart rhythms), detect if there is an electrolyte imbalance,
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detect adverse affects resulting from hypertension, and follow the heart’s response to medication. The medical assistant is usually the health care professional responsible for performing the EKG in the provider’s office. Precise skills and knowledge are essential when performing all forms of cardiac testing. Other types of cardiac testing in which the medical assistant may have a role include Holter monitor studies and cardiac stress testing.
TYPES OF PROVIDERS WHO SPECIALIZE IN TREATING CARDIOVASCULAR SYSTEM DISEASES AND DISORDERS Physicians who specialize in diseases and disorders of the heart are referred to as cardiologists. Cardiovascular surgeons are physicians who conduct surgical procedures on the heart and surrounding vessels. Medical assistants frequently work in cardiology practices. Knowing the information in this chapter will be beneficial to medical assistants working in cardiac specialty practices as well as in general practice settings.
PATIENT SCREENING FOR THE CARDIOVASCULAR SYSTEM Medical assistants may have the responsibility of screening patients prior to provider examination. The depth of screening will be established by office protocol, but in
general, medical assistants should be able to ask a series of questions related to the patient’s symptoms. Table 15-1 lists types of questions that are typically asked when patients complain of cardiac symptoms and lists common procedures that coincide with symptoms. Important note: Medical assistants should never perform any procedure unless directed to do so by the provider; however, they can set up various equipment and supplies to help save time in the event that testing is ordered.
ANATOMY OF THE HEART The heart (Figure 15-1) is a muscle made up of four chambers; two upper chambers known as the right and left atria, and two lower chambers known as the right and left ventricles. The right and left sides of the heart are separated by a wall or septum, keeping the blood contained on each side. Deoxygenated blood returning from the body’s tissues enters the right atrium through the superior and inferior vena cava, the largest veins in the body. The blood then passes through the tricuspid valve and enters the right ventricle, which forces the blood through the pulmonary semilunar valve and into the pulmonary artery. The blood continues its journey until it reaches the lungs, where it picks up oxygen and drops off carbon dioxide. The now oxygen-rich blood leaves the lungs through the pulmonary vein, and enters the left atrium. The blood flows through the bicuspid/mitral valve into the left ventricle, which pumps the blood through the aortic semilunar valve and into the aorta. The aorta branches off into a network of arteries that carry the blood out to the body’s tissues.
TABLE 15-1 Patient Screening and Instructions for the Cardiovascular System ASK THE PATIENT: “ARE YOU EXPERIENCING ANY. . .”
Difficulty in breathing; shortness of breath; chest pain or pressure; radiation of pain to the arms, neck, or jaw, heart palpitations; nausea or vomiting; swelling in the hands or feet; fainting episodes? Do you have any history of cardiovascular disease?
DISROBING INSTRUCTIONS
Remove all garments from the waist up.
VITAL SIGNS
All
EQUIPMENT
EKG unit, pulse oximeter, oxygen, crash cart, and IV materials
POSSIBLE PROCEDURES
EKG, pulse oximetry, defibrillation
C A R D I O VA S C U L A R E X A M S A N D P R O C E D U R E S
Aorta Superior vena cava
Left pulmonary artery
Right pulmonary veins
Left pulmonary veins
Right atrium
Left atrium Left atrioventricular (bicuspid) valve
Right atrioventricular (tricuspid) valve
Left ventricle Right ventricle
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Atrioventricular (AV) node
Sinoatrial (SA) node
Bundle of His Right and left bundle branches
Semilunar valves
Inferior vena cava
❖
(AV) Bundle
Purkinje fibers
Septum
FIGURE 15-1 The anatomy of the heart
FIGURE 15-2 The electrical conduction system of the heart
THE HEART’S ELECTRICAL CONDUCTION SYSTEM
heart chambers relax for a brief period, a phase referred to as diastole. It is the electrical activity within the heart that causes these events to occur and this activity is recorded by the EKG machine or electrocardiograph. The graphic representation of the cardiac cycle is known as the EKG or electrocardiogram. The EKG cycle (Figure 15-3) is a graphic representation of the cardiac cycle and is represented by a series of waves and complexes known as the P wave, QRS complex, and T wave and sometimes a small wave known as the U wave. Each wave represents the activity of the heart as the electrical impulse travels across its surface. The following is a list of terms that describes the events that occur during the cardiac cycle:
The electrical conduction system of the heart (Figure 15-2) is made up an elaborate group of electrical cells that work with the heart’s muscle cells, causing the heart’s chambers to contract in a sequential fashion. The sinoatrial (SA) node—known as the “natural pacemaker” of the heart, located in the top portion of the right atrium—sparks an electrical impulse (a period referred to as depolarization), which commences the heart to “beat.” This electrical impulse spreads throughout the right and left atria, causing them to contract. The impulse then travels to the atrioventricular (AV) node, located at the base of the right atrium, which transmits the signal to the bundle of His. The bundle of His splits into the right and left bundle branches and carries the impulse to the Purkinje fibers, scattering the impulse across the right and left ventricles and forcing them to contract. The heart relaxes for a short time (a period referred to as repolarization) and the cycle begins again when the SA node sparks another electrical impulse.
THE CARDIAC CYCLE One complete heartbeat is known as a cardiac cycle. During the cardiac cycle, the atria contract first, then the ventricles. The contraction phase of the atria and ventricles is referred to as systole. Following contraction, the
❖ P wave: This wave represents atrial depolarization, which is associated with atrial contraction. ❖ QRS complex: This complex represents ventricular depolarization, which is associated with ventricular contraction. This series of waves is considered a complex because it combines the Q, R, and S waves together. ❖ T wave: This wave represents ventricular repolarization or ventricular rest or recovery. ❖ U wave: This is a small wave that sometimes occurs after the T wave. Its true source is not known, but it is sometimes seen in patients with electrolyte imbalances and with the use of particular medications. It is also sometimes seen in patients with heart disease.
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Q wave is a negative deflection or wave. R wave is a positive deflection or wave. S wave is a negative wave. T wave is a positive wave and represents ventricular repolarization or diastole. U wave (occasionally seen in some patients) is a positive deflection and associated with repolarization.
duce the tracing, and each lead must be marked for later identification and mounting. The single-channel machine produces a tracing that must be cut and mounted before placement in the patient’s chart. Special mounting forms that are the size of a standard sheet of paper can be used for mounting purposes. Figure 15-4 represents a single-channel tracing.
Multichannel EKG Unit R Ventricle Atrial Cycle repolarization depolarization V begins (recovery diastole) (contraction systole) O again T L P U P T T A P U-wave G Q occurs in E some patients S Ventricle depolarization (contraction systole) TIME
The multichannel EKG unit can record several leads at the same time. The 12-lead tracing is produced quickly on a special 8.5 ⫻ 11 inch piece of paper that fits easily into the patient’s chart and requires no mounting. The three-channel machine is most commonly used in the provider’s office and records three leads simultaneously; however, some units can run a variety of combinations, including 3, 4, 6, or 12 leads all at the same time. Figure 15-5 shows examples of two multichannel EKG units and Figure 15-6 illustrates a tracing from a multichannel unit.
FIGURE 15-3 A graphic representation of each wave of the EKG cycle
Automated EKG Units
❖ Baseline: This is a flat, horizontal line separating EKG cycles. The baseline (or isoelectric line) is used as a reference point when centering the tracing. The waves will deflect positively or negatively from the baseline. A positive deflection is characterized by an upward deflection above the isoelectric line. A negative deflection is characterized by a downward deflection below the isoelectric line. ❖ Segment: This is the space between two waves. ❖ Interval: This is the length of a wave.
The majority of today’s EKG units are automated, which means that once the patient is properly hooked up and the appropriate data have been entered, the medical assistant just presses a button and the unit does the remainder of the work. The automatic EKG records a preset length of each lead, moving through each lead until a complete 12-lead tracing is produced. The automatic unit also has a manual control knob that may be used when a longer tracing of a specific lead is required. Many automated EKG units are also interpretive, meaning that they are equipped with a computer program that provides an analysis of the tracing as it is being recorded. This feature assists the provider in formulating a diagnosis and determining a treatment plan.
TYPES OF EKG UNITS Several different types of electrocardiographs are available for use in the provider’s office. The type used in each office will depend on the type of specialty and the preference of the practitioner.
Single-Channel EKG Unit A single-channel electrocardiograph records a standard 12-lead EKG one lead at a time. The machine can be operated either manually or automatically. If operated automatically, the single-channel EKG can produce a recording of all 12 leads in less than one minute. If operated manually, the lead selector switch must be turned by hand to each lead setting in order to pro-
Telephone Transmission Specialized EKG units have been designed to transmit recordings over telephone lines. Once the recording is transmitted, either a cardiologist or a computer interprets the EKG. The interpretation results and a printout of the tracing are then sent back to the office. Electronic medical records will eventually minimize or alleviate the need for this type of unit.
Facsimile EKGs can also be transmitted directly through a fax machine to another site for quick interpretation by
C A R D I O VA S C U L A R E X A M S A N D P R O C E D U R E S
Charles Williams PATIENT SEX AGE HEIGHT WEIGHT DRUGS RATE:ATRIAL INTERVAL: PR QRS QT INTERPRETATION
NO. B/P VENT. RHYTHM
INTERPRETED BY
LEAD III
AVR
AVL
AVF
V1
V1
aVF
V2
V3
V2
V4
V4
Dr. T. Winston Lewis
LEAD II
aVL
325
DATE 11–1–20XX POSITION AXIS
LEAD I
aVR
❖
V3
V5
V6
V5
V6
FIGURE 15-4 An example of a mounted EKG tracing from a single-channel machine
FIGURE 15-5 (a) Portable Eclipse 850 EKG (Courtesy of Spacelabs Medical, Inc.); (b) Eclipse LEII multichannel (Courtesy of Spacelabs Medical, Inc.)
(a)
(b)
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Standard limb or Bipolar leads
Augmented leads
Chest (Precordial) leads
Standardization quality checks 10 mm
Rhythm strip Standard speed
FIGURE 15-6 An example of an EKG tracing from a multichannel machine
EKG EQUIPMENT AND SUPPLIES The EKG unit consists of the electrocardiograph instrument and a cable. The cable hooks into the unit and has 10 wires with small alligator clips that hook directly to the electrodes. The wires and clips are very fragile and
E M R A P P L I C AT I O N Medical equipment manufacturers recognize the surge of medical establishments that are moving toward electronic medical records. As a result, these manufacturers are working closely with EMR software vendors to manufacture diagnostic equipment that will interface directly with their software products. Diagnostic equipment, such as electronic blood pressure equipment, pulse oximeters, pulmonary function units, and
electrocardiographs are now able to be linked directly with the practice’s EMR software. This function alleviates the need to scan the information into the EMR, which saves a great deal of time and reduces potential errors from scanning diagnostic reports into the wrong electronic charts. It also saves the establishment a great deal of money in purchasing specialized paper that will only work with specific equipment.
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a specialist. This eliminates the need for copying the tracing and then sending it via fax machine, thus saving time. Many EMR programs have facsimile options available so that EKGs can be faxed directly from the patient’s EMR to the specialist’s office in the event that the specialist’s office does not have electronic capabilities.
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must be handled with care. In order to get a good quality tracing, the alligator clips must make contact with the electrolyte on the electrode pads. The galvanometer changes the voltage coming from the patient's heart into a mechanical action that produces a tracing and the amplifier converts the normally weak signal into a more readable signal for the output device. Many of the latest electrocardiographs are equipped with alphanumeric keypads to enter pertinent patient data and a lighted display monitor to view the tracing and particular settings. Menu options allow the user to change various settings such as the paper speed and the amplitude or height of waves that are too small or too large. Internal filters assist in diminishing variables that can interfere with the electrocardiogram, such as somatic tremors (shivering or shaking from the patient) and electrical interference coming from other equipment. Today’s EKG technology allows users to store data, print a copy of the EKG, or transmit the EKG electronically to the patient’s electronic medical record.
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In addition to the EKG unit, specialized paper is needed to record the tracing, along with electrodes and some form of electrolyte.
EKG Paper Special paper is required for recording an EKG. The color of the graphing lines on the EKG paper may be red, black, or blue, depending on the manufacturer of the paper. The paper is covered by a white plastic or wax coating. As the heated stylus (the wire that produces the tracing) moves in response to the patient’s heartbeat, it melts the plastic, resulting in a tracing that looks as if it were made with ink. The EKG paper is imprinted with two sets of squares. Each small square is 1 millimeter (mm) high and 1 mm wide, while each large square is 5 mm by 5 mm and consists of 25 small squares (Figure 15-7). Each large square is outlined in darker ink for easy counting. Each small square is equal to 0.04 seconds and each large square is equal to 0.2 seconds. The vertical lines measure the amplitude or how high the complex deflects,
3 sec
3 sec
V O L T A G E
Small square
Large square
0.2 sec
1 mm
TIME 0.5 mV
❖
5 mm
0.04 sec
FIGURE 15-7 EKG graph paper illustrating the size of the blocks used to measure the time and voltage of heartbeats
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and the horizontal lines measure the timing of the impulses. After the recording is produced, the provider is able to count the number of squares on the paper and perform a calculation to determine the time it takes for each deflection and the amount of voltage or cardiac electrical activity present. These calculations assist the provider in determining various heart abnormalities.
Paper Speed The EKG paper normally runs through the machine at a rate of 25 millimeters per second (mm/sec). If the heart rate is elevated and the complexes are spaced too closely together for an accurate interpretation, the paper speed may be increased to 50 mm/sec, which will spread the complexes farther apart. The change in paper speed is usually automatically indicated at the top or bottom of the tracing when using automated units. When using older, nonautomated units, the medical assistant may need to manually write the change on the strip.
Electrodes and Electrolyte Electrodes, also known as sensors or leads, are attached to the patient and designed to detect electrical activity coming from the heart. The majority of electrodes are disposable self-adhesive pads (Figure 15-8) made of conductive material that contains an electrolyte solution that helps conduct the electrical current. The electrode pads are placed on the skin at various locations on the four extremities and throughout the anterior chest. The impulses are transmitted from the electrodes through the lead wires to the EKG
FIGURE 15-8 An example of disposable electrodes
machine. Three basic types of electrodes are plate or metal electrodes, suction bulbs, and the disposable self-adhesive electrodes mentioned earlier. The plate electrodes and suction bulbs are more antiquated and not readily used today. When using the plate or suction bulb style of electrodes, an electrolyte solution is placed on the patient’s skin prior to attachment of the electrodes. Electrolyte is manufactured in different forms such as lotions, gels, and premoistened pads. The skin should be cleansed and dried before applying the electrodes. Particularly hairy areas should be shaved.
Care and Maintenance The EKG machine requires minimal care and maintenance. The machine itself should be cleansed with a soft cloth and mild detergent to remove surface dirt and dust and the lead wires or cables should be disinfected on a regular basis. Never submerge the cable or wires into liquid and never spray the actual unit with a solution. Always spray the solution onto the cloth and then wipe the unit. This will prevent moisture from getting into the unit and causing damage. If metal electrodes are used, they should be cleansed after each use with a mild abrasive cleanser and thoroughly dried.
EKG LEAD PLACEMENT A standard EKG consists of a total of 12 leads; however, only 10 sensors are attached to the patient’s body. Each lead transmits a recording of the electrical impulses coming from the heart at different angles. What influences a deflection within the cardiac cycle of a particular lead to be positive or negative is contingent on the geometrical angle that the heart is being viewed from, and the direction that the current is flowing as
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FI E L D S M A R T S When working in an office that operates more than one EKG unit, make certain that your electrodes correspond with the unit you are using. Using electrodes that are manufactured for a different unit can cause a poor tracing. Also, it is important to make certain that the alligator clips located at the distal tips of the lead wires are free of lint and other particles that could interfere with the tracing.
C A R D I O VA S C U L A R E X A M S A N D P R O C E D U R E S
the heart depolarizes. Waves of depolarization moving toward a positive pole usually result in a positive deflection; waves of depolarization moving away from a positive pole usually result in a negative deflection. If a particular lead produces a deflection other than what is anticipated, it could indicate heart pathology or a problem with the placement of the electrodes. The limb electrodes are placed on the fleshy, nonbony part of the patient’s upper arms and lower legs (Figure 15-26). The tabs on the electrodes should be pointing downward on the arms and upward on the legs to reduce tension or pulling on the electrodes. Electrode tabs on the chest should also be facing downward and placed on the wall of the chest at the appropriate spaces.
Standard Limb Leads Leads I, II, and III are known as the “standard limb leads” and are often referred to as bipolar leads because they record the electrical activity from two limb electrodes at the same time. The electrode wires are color-coded and include the abbreviation for the part of the body where they should be applied (see Table 15-2). These leads measure the electrical activity of the heart between a negative (–) pole and a positive (+) pole. Lead I records the difference in voltage between the RA (– pole) and LA (+ pole); lead II records the difference in voltage between the RA (– pole) and LL (+ pole); and lead III records the difference in voltage between the LA (– pole) and LL (+ pole). Note: the RL wire is used as a reference point or ground wire and is not part of the recording even though an electrode is placed on the right leg.
Augmented Leads The next three limb leads, aVR, aVL, and aVF, are known as the augmented leads and referred to as unipolar because only a single positive electrode is referenced against a “null point” (a point with little or no TABLE 15-2 Standard Limb Leads
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significant electronic variation) between the remaining limb electrodes. The aV stands for augmented voltage and is referred to as augmented because the electrical impulses from these three leads are very small and the EKG machine must augment or increase their size to make them readable. The last letter in each of the augmented leads is an abbreviation that relates to the positive pole or electrode used in each lead. Lead aVR (right arm) records the difference in voltage between the RA (the + pole) and a midpoint between the LA and LL (the negative reference point). Lead aVL (left arm) records the difference in voltage between the left arm (+ pole) and a midpoint between the RA and LL (negative reference point). Lead aVF (foot or left leg in this case) records the difference in voltage between the left leg (+ pole) and a midpoint between RA and LA (negative reference point). Figure 15-9 illustrates the pathways of impulses for the bipolar leads and augmented leads.
Chest or Precordial Leads The chest or precordial leads are the last six leads of the standard 12-lead EKG and do not require any amplification because of how close they are to the heart. These leads are also unipolar and are designated as leads V1 through V6. Correct placement of the chest electrodes is crucial to obtain an accurate reading. The precordial leads record the electrical activity from a null or midpoint within the heart to one of the six landmarks on the chest wall where an electrode is placed. Anatomical placement of chest electrodes is as follows: ❖ V1: Fourth intercostal space at the right margin of the sternum ❖ V2: Fourth intercostal space at the left margin of the sternum ❖ V3: Midway between V2 and V4 ❖ V4: Fifth intercostal space at the midclavicular line ❖ V5: Same horizontal level as V4 at the left anterior axillary line ❖ V6: Same horizontal level as V4 and V5 at the left midaxillary line
LIMB ELECTRODE
WIRE COLOR
ABBREVIATION
Right arm
White
RA
Left arm
Black
LA
Lead Marking Codes
Right leg
Green
RL
Left leg
Red
LL
All leads must be marked for identification and mounting purposes. Older units use a special type of coding similar to Morse code that uses “dots and dashes” to mark each lead. The operator manually marks each
Figure 15-10 illustrates the correct positioning of the chest electrodes and the standard coding used for all leads on older units.
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(A) Standard limb or bipolar leads Electrodes Connected Lead I
LA and RA
Lead II*
LL and RA
Lead III LL and LA * Also used for rhythm strip
Lead I
Lead II
Lead aVR
Lead aVL
Lead III
(B) Augmented limb leads aVR
RA and (LA-LL)
aVL
LA and (RA-LL)
aVF
LL and (RA-LA)
Lead aVF
FIGURE 15-9 Lead placement and the pathways of impulses for bipolar leads and augmented leads. The arrows are pointing to the positive electrodes or poles. FIGURE 15-10 International marking codes for the 12-lead EKG (Courtesy of Spacelabs Medical, Inc.) STANDARD LIMB LEADS LEAD MARKING CODE
LEAD
LEAD 1
ELECTRODES CONNECTED
LA and RA
LEAD 2
LL and RA
LEAD 3
LL and LA
COLORCODE BODY
INSERT
RL
GREEN
GREEN
LL
RED
RED
RA
WHITE
GRAY
LA
BLACK
GRAY
AUGMENTED LIMB LEADS LEAD MARKING CODE
LEAD
ELECTRODES CONNECTED
aVR
RA and (LA-LL)
aVL
LA and (RA-LL)
aVF
LL and (RA-LA)
COLORCODE BODY
INSERT
RL
GREEN
GREEN
LL
RED
RED
RA
WHITE
GRAY
LA
BLACK
GRAY
CHEST LEADS LEAD MARKING CODE
LEAD
ELECTRODES CONNECTED
V1 Fourth intercostal space at right margin of sternum
COLORCODE BODY
INSERT
V1
V1 and (LA-RA-LL)
V1
BROWN
RED
V2
V2 and (LA-RA-LL)
V2
BROWN
YELLOW
V3
V3 and (LA-RA-LL)
V3
BROWN
GREEN
V4
V4 and (LA-RA-LL)
V4
BROWN
BLUE
V5
V5 and (LA-RA-LL)
V5
BROWN
ORANGE
V6
V6 and (LA-RA-LL)
V6
BROWN
VIOLET
V2 Fourth intercostal space at left margin of sternum V3 Midway between position 2 and position 4 V4 Fifth intercostal space at junction of left midclavicular line V5 At horizontal level of position 4 at left anterior axillary line V6 At horizontal level of position 4 at left midaxillary line
1 2
3
4 5 6
C A R D I O VA S C U L A R E X A M S A N D P R O C E D U R E S
lead by pressing the lead marker button at the beginning of the lead tracing. The majority of today’s models will automatically mark each lead and will print the actual name of the lead at the top of the EKG tracing toward the beginning of each lead.
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FI E L D S M A R T S When performing an EKG, if the patient’s R waves are large and deflecting outside of the graphing lines on the EKG paper, you may need to either manually lower the baseline, or decrease the sensitivity control or gain to “5” or “1⁄2.” This will cause the stylus to move half as high (5 mm). If waves are too small and difficult to read, you may need to increase the sensitivity to “20” or “2,” which will double the size of the impulse; the stylus will deflect 20 mm high. Always perform a standardization when changes are made to the sensitivity so that the practitioner is aware of the change. Record another standardization when you return the sensitivity back to its original setting.
RHYTHM STRIP Sometimes the provider will order a rhythm strip, which is a separate 12 inch recording of a particular lead, generally lead II. However, this may vary in some instances. A rhythm strip assists the provider in detecting abnormalities in the patient’s heart rhythm that may not be detectable in the standard leads due to the shorter representations of each lead. The majority of multichannel units will perform this function automatically during the standard 12-lead EKG.
STANDARDIZING THE EKG To ensure that the EKG machine is working properly, a standardization mark is made at the beginning of each lead, or group of leads when using a multichannel unit. This function is performed automatically when using automated units but may need to be performed manually in older units. Standardization serves as quality assurance that the electrocardiograph is measuring the impulses properly. According to universal standard, 1 millivolt (mV) of cardiac activity will deflect the stylus 10 mm high, which is 10 small or two large vertical squares on the EKG paper. The sensitivity control, also referred to as “gain” on many units, controls the size of the standard and amplitude of the heart beat and is normally set on the number “10” or “1” depending on the particular unit. At the beginning of the EKG, the automatic electrocardiograph will place 1 mV of electricity into the unit, triggering the stylus to move 10 mm high. This process mimics normal heart activity. If the standardization extends above or below 10 mm while on this setting, the medical assistant should seek technical assistance. The amplitude of the waves may be adjusted for abnor-
mally large or abnormally small beats by changing the sensitivity or gain setting. Figure 15-11 shows examples of the standardization mark when the sensitivity is set at 5 mm, 10 mm, and 20 mm.
PERFORMING THE RESTING 12-LEAD EKG When performing a standard resting 12-lead EKG, no matter what type of EKG unit is used, the placement of electrodes, instructions for patient preparation, lead wire connections, and troubleshooting to correct artifacts are basically the same. Although the steps are similar, each machine may vary slightly so it is important for the medical assistant to become familiar with the particular unit that is used within the practice. If the practice uses two units, the medical assistant should become familiar with both. (You never know when the unit that you favor will not be available!) Procedure 15-1 lists the steps for performing an EKG using a multichannel unit. FIGURE 15-11 Examples of the standardization mark at different settings: (a) 5, (b) 10, and (c) 20 (Courtesy of Spacelabs Medical, Inc.)
(a)
(b)
(c)
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CR ITI C A L TH I N K I N G C H AL LEN G E
C R I T I C A L T H I N K I NG CHALLENGE
While performing an EKG tracing, you notice that the R waves are going off the graphing lines on the EKG paper. 1. What type of adjustments can you make to keep the R wave within the graphing lines? 2. What adjustment can you make if the waves are barely visible?
You view a tracing that you just performed on a patient and notice that there is a wandering baseline on Leads I and II and Lead AVR. You do not notice the interference on any other leads. 1. What might be the cause of the interference? 2. What lead should you inspect first? 3. What steps can you take to correct the interference?
MOUNTING THE EKG TRACING
appears, the medical assistant should know how to locate the source and correct it. The most common types of artifacts are listed in Table 15-3.
ARTIFACTS In order for a provider to accurately interpret an EKG tracing, it must be performed correctly and be free of artifacts or unwanted interference. If an artifact
CARDIAC ARRHYTHMIAS Cardiac arrhythmias, sometimes referred to as dysrhythmias, are irregularities in the heart’s rhythm. They can be caused by either physiological or pathological interruptions in the discharge of electrical impulses from the SA node or any other conductive tissue of the heart. The medical assistant should be able to recognize basic arrhythmias so that the proper steps can be taken. The normal EKG cycle is comprised of a P wave, QRS complex, and T wave. The sequence should repeat itself in a continuous, even pattern. Any extra beats, abnormal heart rates, or abnormal rhythms are considered arrhythmias. Normal sinus rhythm is the term used to describe an EKG that falls within normal limits (WNL). The normal adult heart rate ranges from
PAT I E N T T U T O R In order to achieve the best EKG tracing possible, patients should be told what to expect and how to relax during the procedure. Some patients are misinformed prior to the procedure and are worried that they may receive some kind of electrical shock from the wires attached to their body. Additionally, patients should be questioned regarding comfort. If the patient is in pain while lying flat or becomes chilled, it could result in somatic interference on the trac-
ing. Make the appropriate adjustments before starting the procedure. To assist with relaxation, instruct the patient to lay still and close the eyes. Share relaxation techniques, such as asking the patient to take in a deep breath and blow it all out just prior to the procedure, or to imagine sitting on a beach somewhere with the palm trees gently swaying in the wind. A relaxed patient will assist you in producing a better quality EKG tracing.
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There are several different types of mounting forms available. The choice will depend on the type of machine used and the preference of the office. Multichannel units will produce tracings on a standard 8.5 ⫻ 11 inch sheet of paper that does not require mounting. When mounting is necessary, the medical assistant should allow the provider to check the entire tracing before the mounting is performed. Each lead must be identified and any unusual variances should be mounted if possible. Pertinent information such as the patient’s name, age, gender, height, weight, blood pressure, and particular medications should be recorded on the designated lines on the mounting card.
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TABLE 15-3 Common Artifacts That Appear on an EKG Tracing TYPE OF ARTIFACT Somatic tremor
Wandering baseline
Interrupted baseline
POTENTIAL CAUSES
CORRECTION TECHNIQUES
Muscle tremors: Voluntary: Occur when the patient moves, talks, coughs, etc. Involuntary: Occur as a result of a physical condition, such as Parkinson’s disease.
Fully explain the procedure to the patient and make the patient as comfortable as possible. Place a pillow under the patient’s head, and make sure the room is warm enough. Check to see if there is a filter on the unit for somatic or muscle interference; if there is, make the appropriate adjustments.
PICTURE OF ARTIFACT
Somatic tremor artifact; fuzzy appearance with jagged peaks and irregular spacing
The electrode wire is not securely attached to the electrode.
Clips and lead wires should be firmly attached to the electrodes. The patient cable should not dangle or pull on the electrode.
The alligator clip that is attached to the electrode is not correctly positioned.
The alligator clip needs to be positioned so that it Wandering baseline artifact comes into contact with the electrolyte on the electrode pad.
Body creams, lotions, or oils.
Clean the area with alcohol where the electrode will be placed to remove any skin products.
A broken patient cable wire.
Replace the wire.
The lead wire becomes detached from the electrode.
Be sure the wire is securely attached to the electrode.
Interrupted baseline artifact
AC current
Most of today’s units have internal filters that filter out AC; if a filter is not available, some common causes of AC interference include:
Check to make certain that the filter for AC is depressed or activated. If still having problems:
Other electrical equipment in the room such as autoclaves, lamps, electrical exam tables, or electrical wiring in the walls, floors, and ceiling.
Unplug equipment in the immediate area. Move the EKG machine to a different location.
Improper grounding of the EKG machine.
The machine should be automatically grounded when plugged in with a three-prong plug.
The lead wires are crossed or twisted and not in alignment with the body.
Make sure the lead wires are not tangled and that they follow the patient’s body contour.
AC or electrical interference artifact
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FIGURE 15-12 A heart rate of less than 60 beats per minute, known as sinus bradycardia
FIGURE 15-13 A heart rate faster than 100 beats per minute, known as sinus tachycardia
60 to 100 beats per minute (BPM). Sinus bradycardia (Figure 15-12) is the term used to define a heart rate below 60 BPM, while sinus tachycardia (Figure 15-13) refers to a heart rate above 100 BPM.
ters, shortness of breath, apprehension, and dizziness. This arrhythmia is common in healthy individuals but can occur in patients with cardiac disease.
Premature Atrial Contractions
Atrial fibrillation is indicated by extremely rapid and incomplete contractions of 400 to 500 BPM. The P waves are small, irregular, and cannot be differentiated. This arrhythmia can appear in healthy individuals as well as in those with mitral valve disease, rheumatic heart disease, hypertension, and coronary artery disease. Figure 15-16 shows three different atrial arrhythmias as they appear on the EKG tracing.
The condition known as premature atrial contractions (PACs) is usually considered a benign condition and ordinarily poses no health threat to the patient. However, in some cases PACs may be present in more serious cardiac conditions. PACs commonly occur in patients who smoke and use caffeine or other stimulants. During a premature atrial contraction, the P wave is shaped differently than the P wave of a normal cardiac cycle (Figure 15-14).
Paroxysmal Atrial Tachycardia Paroxysmal atrial tachycardia (PAT) is one of the most common cardiac arrhythmias. PAT is characterized by a sudden onslaught of increased heart rate ranging from 160–250 BPM. The increase lasts only a few seconds and abruptly returns to the pre-PAT rate (Figure 15-15). Patients usually complain of heart flut-
Atrial Fibrillation
Premature Ventricular Contractions Premature ventricular contractions (PVCs) occur on the EKG tracing before a normally conducted beat. They are characterized by a beat that comes early in the cycle, the absence of the P wave, a wide QRS complex, and a T wave that deflects opposite the QRS complex. Following a PVC, there is an identifiable pause before the next normal cycle (Figure 15-17). This particular arrhythmia can be found in individuals who use
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P wave R wave
FIGURE 15-14 An example of premature atrial contractions (PACs)
FIGURE 15-15 An example of paroxysmal atrial tachycardia (PAT)
FIGURE 15-16 An example of atrial fibrillation
Normal Normal
FIGURE 15-17 An PVC PVC
example of premature ventricular contractions (PVCs)
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tobacco, alcohol, caffeine, and certain medications as well as in individuals with hypertension, coronary artery disease, and lung disease with hypoxia.
Ventricular Tachycardia Ventricular tachycardia (V-tach) occurs when three or more PVCs appear in a row and the heart rate ranges from 150 to 250 BPM. The P wave is indistinguishable and the QRS complex is wide and distorted (Figure 15-18). V-tach is seen in individuals with both acute and chronic heart disease, coronary artery disease, and as a result of a myocardial infarction. This arrhythmia is life-threatening and can deteriorate into ventricular fibrillation and cardiac arrest.
Ventricular Fibrillation Ventricular fibrillation (V-fib) is the most serious of the cardiac arrhythmias. It is characterized by uncoordinated beats that cause a quivering or twitching of the ventricles. Because the ventricles are not fully beating, no blood is being pumped out to the tissues of the body, which can cause tissue death. V-fib is common during an acute myocardial infarction and is also seen in patients with existing cardiac disease. This arrhyth-
FIGURE 15-18 An example of ventricular tachycardia
FIGURE 15-19 An example of ventricular fibrillation (V-fib)
mia can cause sudden death and an attempt to correct it must be initiated immediately (Figure 15-19). Figure 15-20 displays two EKG tracings from a patient who has suffered a myocardial infarction.
DEFIBRILLATION Defibrillation is defined as stopping fibrillation of the heart muscle by physical means or by the use of drugs. An electrical device known as a defibrillator is used to apply countershocks to the heart through pads or electrodes placed on the chest wall. The purpose of the countershock is to convert a cardiac arrhythmia back to a normal sinus rhythm. This process is known as cardioversion. Many ambulatory care facilities keep a defibrillator on a crash cart for easy and quick access during an emergency. It is the medical assistant’s responsibility to routinely check the defibrillator to make sure it is in good working order. Portable defibrillators known as automated external defibrillators (AEDs) are not only found in medical facilities; they may also be found in police cruisers, schools, college campuses, airports, and anywhere large numbers of people gather. Some patients who
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I
AVR
V1
V4
II
AVL
V2
V5
III
AVF
V3
V6
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RHYTHM STRIP: II 25 mm/sec; 1 cm/mV
FIGURE 15-20 An EKG tracing from a patient who has had a previous myocardial infarction
may be at risk of suffering a cardiac arrest even keep these devices in their homes. The AED is portable and battery-operated and can be used by anyone who has been properly trained. Once only emergency personnel were trained to use an AED, but now nonhealth care workers are trained and certified to operate this device. Refer to Chapter 35 for more information on AEDs.
occur and records those symptoms in a special diary. The cardiologist then compares the symptoms with the tracing made at the time of the event. This assists in the diagnosis of sporadic arrhythmias that may not show up during routine EKG testing.
MISCELLANEOUS CARDIAC DIAGNOSTIC TESTING
supplies
Various equipment and techniques are available to diagnose cardiac problems in addition to the EKG. Most are noninvasive, painless, and require little or no patient preparation. The majority of these procedures can be performed on an outpatient basis.
Holter Monitor The Holter monitor (Figure 15-21) is a portable ambulatory heart monitoring device that continuously looks at a patient’s heart over a prolonged period of time (usually 24 hours but may be longer in some instances). Monitoring is useful for patients who experience sporadic cardiac symptoms, such as fatigue, chest pain, dizziness, and fainting or syncope. The patient depresses an event button when irregular symptoms
FIGURE 15-21 An example of one type of Holter monitor and
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The Holter monitor is a battery-operated recorder that uses a cassette or digital memory card to record the tracing. It may be placed in a pouch and worn around the patient’s waist with a belted fastener or strapped in place over the patient’s shoulder. Newer smaller models are placed in a small pouch and fastened around the patient’s chest, making it much easier for the patient to move around. A total of four or five electrodes (depending on the unit) are placed on the patient’s chest at different locations (Figure 15-22); these locations are different from the locations for chest electrodes on a standard 12-lead EKG. The electrodes are usually made of foam, contain electrolyte, have an adhesive backing and a snap on the front where the wires attach to the electrodes. The medical assistant’s duties include preparing the patient, explaining the procedure, attaching and removing the monitor, and stressing to the patient the importance of keeping an accurate and complete activities diary. The patient should be advised to maintain usual daily activities, with the exception of swimming, showering, or taking a bath while wearing the monitor. Skin lotions and oils as well as chest hair will need to be removed prior to application of the leads. The chest is normally abraded with gauze squares or a special prep kit to ensure that sites are free of all dirt and oils. The chest should be thoroughly dried before application. Once the electrodes are properly applied, they are connected to the monitor by lead wires. All lead wires must be securely attached to the electrodes to FIGURE 15-22 Electrodes must be properly placed according to the manufacturer’s directions to ensure an accurate tracing. Zymed EASI Lead Placement Red Top of sternum
Green Left upper chest Black 5th intercostal midaxillary, left White 5th intercostal midaxillary, right
Brown 5th intercostal on lower sternum
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C R I T I C A L T H I N K I NG CHALLENGE After attaching the Holter monitor electrodes to the chest of a male patient, you notice that one of the electrodes is not sticking very well. The patient has some hair in the area where the electrode is not sticking, but you didn’t shave the area because you didn’t think it would cause a problem. The provider is waiting on you to room another patient. 1. What is the best way to proceed? 2. How will you make certain that this never occurs again?
prevent an interruption in the tracing. Once the patient is connected, the monitor must be checked to ensure that it is working properly. One end of the test cable is attached to the monitor and the other end is connected directly to the EKG machine. A short baseline reading is recorded to check for correct wave activity and the presence of artifacts. Any artifacts or problems with the unit should be remedied before the patient leaves. It is important that the patient be given guidelines to follow to ensure an accurate recording. During the 24-hour monitoring period, a complete and accurate activity diary must be maintained. All activities and changes in emotional state should be noted in the diary along with the time of their occurrence. Figure 15-23 is one example of a diary page used along with the Holter monitor. If the patient experiences any symptoms such as shortness of breath, chest pain, dizziness, or palpitations during the monitoring period, this should be recorded in the diary along with the time of the occurrence. Some monitors are equipped with an event button or marker that can be used when the patient experiences unusual symptoms. When the patient depresses the button, the monitor automatically places a mark on the recording that alerts the person interpreting the tape to look for an abnormality. Once the 24-hour monitoring period has ended, the patient is instructed to return to the office to have the monitor removed. The tape is then evaluated by a special Holter scanning device or by computer. The analysis is usually performed in a hospital EKG department. The provider usually receives a written report within 24 hours. The report will include sample printouts of
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HOLTER MONITOR DIARY During the Holter monitoring period it is important to keep a diary of activities that you perform as well as symptoms you experience. This diary will assist the physician in comparing changes that occur on the ECG with the activity you were performing when the changes occurred. The following is information that should be listed on the diary record:
• Date: Because the monitoring period can be anywhere from 24 to 72 hours, it will be important to list the date your symptoms occur. • Time: Record the time for all activities you perform or symptoms you experience. This will assist the physician in matching this information up with changes that occur in the tracing. • Activities or Events: Record any strenuous activity or activities that can cause changes in your metabolic rate including: walking, exercise, bowel movements, eating, sexual activity, etc. • Symptoms: Record any unusual symptoms that you experience during the testing period such as: shortness of breath, racing heart, dizziness, chest pain, etc. List the activities you were performing when the symptoms began. (Remember to click on the event button on your monitor when symptoms occur.)
DATE
TIME
ACTIVITY
SYMPTOMS
FIGURE 15-23 A patient diary page for Holter monitoring
any abnormalities. Refer to Procedure 15-2 for instructions on Holter monitor placement.
Treadmill Stress Test Providers often order a treadmill stress test for patients who have possible cardiac symptoms but do not show any abnormalities on the standard EKG as well as for patients who are just starting a rigorous workout program who may be at-risk for complications. During exercise on a treadmill, a heavier workload is placed
on the heart, stimulating abnormalities to appear that wouldn’t have appeared without the extra load on the heart. The treadmill stress test is a noninvasive procedure during which the patient walks on a treadmill while connected to an EKG machine. Chest electrodes connected to an EKG machine are placed on the patient prior to the procedure and the speed of the treadmill is gradually increased until the patient can no longer tolerate the exercise. In rare instances, myocardial infarction and serious arrhythmias may occur
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In order to obtain the best results from a Holter monitor recording, the patient must receive proper instructions for wearing and caring for the monitor and what to record in the patient diary. Answer all questions before the patient leaves the office and make certain that the patient is given verbal as well as written explanations of the following guidelines: ❖ Keep the monitor dry at all times (no bathing, showering, or swimming). ❖ Avoid activities that cause excessive perspiration. ❖ Avoid using electrical appliances such as an electric shaver, electric toothbrush, or hair dryer. Using these items may cause electrical interference. ❖ Avoid magnets, metal detectors, and areas with high voltage. Do not sleep under an electric blanket during the monitoring period.
during testing. For that reason, the patient is closely monitored by a physician during the procedure. The medical assistant usually takes blood pressure readings before, during, and following the procedure. If the patient experiences any unusual symptoms, such as chest pain, shortness of breath, or extreme fatigue, the physician will terminate the test. Figure 15-24 shows an example of a treadmill stress test.
Dobutamine Stress Test The provider may order the dobutamine stress test for patients who are unable to exercise on a treadmill due to physical disabilities or age. The drug dobutamine is injected intravenously into the patient, causing the heart rate to increase and simulating exercise. The EKG is recorded and blood pressure readings are monitored in the same manner as the treadmill stress test.
Echocardiography Echocardiography is defined as a noninvasive diagnostic test that uses ultrasound to visualize internal cardiac structures. This method allows for visualization of all heart valves and assessment of heart chamber size.
❖ Immediately depress the event marker when related symptoms are present. ❖ Avoid touching or moving any of the electrodes. ❖ Do not handle or remove the monitor from its pouch. ❖ List all activities such as going up and down the stairs, exercise, smoking, bowel movements, sexual activity, meals (what you consumed, including beverages), medications consumed, and sleep patterns that occur during the monitoring period. ❖ List any extreme emotional states such as anger, stress, etc.
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PAT I E N T T U T O R
Geriatric patients may need help from caregivers or family members when documenting their activities and extreme emotional states.
The patient is placed in a supine position and electrodes from a standard 12-lead EKG are placed on the patient’s extremities. Chest electrodes are not used
FIGURE 15-24 A cardiac stress test (Courtesy of Quinton Cardiology, Inc.)
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during the procedure. A transducer is placed against the patient’s skin and moved over different areas of the chest wall. Sound waves that bounce off the structures of the heart cause echoes to be sent back to the transducer. The echoes are then converted by the ultrasound machine into images that can be examined by a computer and transformed into photographs and films of the heart and its related structures. Figure 15-25 shows an example of an echocardiograph machine.
Cardiac Catheterization Cardiac catheterization is a specialized procedure that allows for visualization of the coronary arteries. This diagnostic procedure allows the provider to determine if there are any blockages present and the amount of occlusion in each artery. Symptoms may or may not
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be present with coronary occlusion and many patients deny symptoms even when an artery is almost completely occluded. During cardiac catheterization, a tiny plastic tube or catheter is threaded through a major vessel, usually the femoral artery, and passed into the heart. Once the catheter is in place, a contrast medium is injected into the heart, which produces a clear image of the coronary arteries, allowing the provider to determine the presence of any blockages. Blood pressure and cardiac output may also be measured during the procedure. If a blockage is detected, a procedure known as angioplasty or “balloon” surgery can be performed at the same time. A device known as a stent can also be placed inside the artery to hold it open and permit blood to flow freely.
Noninvasive Heart Scan FIGURE 15-25 An example of an echocardiograph machine (Courtesy of Siemens Medical Solutions USA Inc.)
A new noninvasive heart scan is now available to evaluate and measure plaque in the coronary arteries by determining the amount of calcium present. The amount of calcium in a coronary artery can indicate the amount of plaque buildup. The heart scan can detect calcium formed over many years before the patient develops cardiac symptoms (chest pain or shortness of breath). If plaque buildup is detected early, treatment can be initiated before the plaque completely occludes the coronary artery or breaks loose, causing a heart attack. The noninvasive heart scan is open, painless, and fast. No needles or contrast media are used and the patient does not even have to get undressed. The scan is 95% to 99% accurate and gives the provider an individualized report for each patient with suggestions for clinical follow-up.
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PROCEDURE 15-1 Perform a Standard 12-Lead Electrocardiogram with a Multichannel Unit Objective: To record an accurate tracing of the electrical activity of the patient’s heart, free from artifacts and interference.
Equipment/Supplies: ❖ ❖ ❖ ❖ ❖
Table with pillow and drape Patient gown Alcohol Cotton balls Tissues
❖ ❖ ❖ ❖ ❖
Razor Machine with patient cable Disposable electrodes EKG tracing paper Mounting form (if applicable)
Note: EKG machines vary from one manufacturer to another. Follow the specific instructions for the unit you currently use.
PROCEDURAL STEPS
RATIONALE
1. Perform the EKG in a quiet, warm, and comfortable room away from other electrical equipment.
Electrical equipment can cause AC interference, resulting in a poor tracing. The patient will be more comfortable if the patient is in a warm and quiet place.
2. Wash your hands and assemble all equipment.
Clean hands prevent the spread of infection.
3. Identify the patient using at least two identifiers, identify yourself, and explain the procedure and why it is important not to move or talk during the tracing.
An informed patient is a relaxed patient. Any movement by the patient can cause interference on the tracing.
4. Instruct the patient to remove all clothing from the waist up and to expose the lower legs. Provide female patients with a gown that opens in the front. Provide all patients with a drape for warmth.
All electrodes must be placed on clean, bare skin. Patients are less likely to move around if they are warm.
5. Prep the patient’s skin by scrubbing the areas where the electrodes are to be placed with alcohol and allowing them to dry. (Dry shave areas on men that are particularly hairy.)
The patient’s skin must be clean and dry and free from lotions and powders for good conductivity between the skin and the electrode. Excessive hair may also interfere with recordings.
6. Place the electrodes on the fleshy part of the upper arm and the inner part of the calf midway between the knee and the ankle (Figure 15-26).
Placing the electrodes over large muscles or bones may cause interference.
FIGURE 15-26 Disposable electrodes should be attached to the fleshy part of the arm and leg of the patient.
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7. Place all six chest electrodes in the correct positions on the chest by counting down the intercostal spaces and locating the proper landmarks (Figure 15-27). Do not trust your eyes alone.
Correct lead placement is essential for an accurate tracing.
8. Place the EKG machine so the power cord points away from the patient. Do not allow the power cord to go underneath the table.
These practices can cause unnecessary AC electrical interference.
9. Securely connect all lead wires to the corresponding electrodes. Be sure that lead wires are pointed downward on the legs and upward on the arms and chest. The patient cable should rest on the table or the patient’s abdomen.
Wires are labeled for your convenience. Attaching wires to the wrong electrodes can cause incorrect readings. Lead wires that cross over each other can cause artifacts on the tracing.
FIGURE 15-27 Chest electrode placement
10. Connect the patient cable to the machine and turn machine to the “ON” position. Enter the patient’s data into the unit by using the keypad. Requested information may include the patient’s name, age, gender, height, weight, and any cardiac medications currently being taken.
(Depending on the type of machine used, allow sufficient time for the machine to warm up.) Different factors can affect the reading so knowing this information will assist the provider in determining why abnormalities may be present.
11. Press the autorun button on the machine and allow the tracing to be recorded. Observe the standardization mark for accuracy.
The standardization mark should measure 10 mm high if the settings are correct and the unit is working properly.
12. Observe the tracing for problems or artifacts. Determine if any changes are needed with regard to the amplitude of the beats (gain or sensitivity control) or the heart’s rhythm (paper speed).
Artifacts or other problems must be corrected to ensure a clear tracing that can be adequately measured.
13. Allow the provider to briefly scan the tracing before disconnecting the patient from the machine.
This eliminates the need to reconnect the patient should the provider request a longer tracing or a repeat of a specific lead.
14. Disconnect the lead wires and remove the electrodes from the patient.
Removing the lead wires before allowing the patient to move can prevent damage to the equipment.
15. Clean the equipment following manufacturer’s guidelines. Replace tracing paper as needed.
Be courteous to your coworkers. Never leave a machine unclean or without sufficient paper for the next tracing.
16. Wash your hands and document the procedure.
Hands must be washed before and after each procedure.
17. Place the tracing in the patient’s chart.
DOCUMENTATION EXAMPLE:
10-03-XX 10:30 a.m.
Performed 12-lead EKG per Dr. Zeller. Pt. tol. well. Lillian Kelly, CMA (AAMA)
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PROCEDURE 15-2 Apply the Holter Monitor Objective: To correctly apply a Holter monitor and properly educate the patient on how to care for the monitor and electrodes, and instruct the patient on what events need to be written in the event journal or diary.
Equipment/Supplies: ❖ ❖ ❖ ❖
Alcohol swabs Razor Gauze Disposable electrodes
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Holter monitor New battery Carrying case Patient activity diary
Note: Holter monitors will differ slightly depending on the specific unit. Check the manufacturer’s instructions for the unit you currently use.
PROCEDURAL STEPS
RATIONALE
1. Wash your hands and assemble the equipment. Place a recording device and a new battery in the monitor.
Clean hands reduce the possibility of transmitting microorganisms. A new battery will ascertain efficient power throughout the entire monitoring period.
2. Identify the patient using at least two identifiers, identify yourself, and explain the procedure. Accurately complete the information in the patient activity diary and instruct the patient to disrobe from the waist up.
A well-informed patient will be able to comply with the requirements for an accurate tracing.
3. Prep the patient’s skin: Dry shave hair, if necessary, and rub the area of skin where electrodes will be placed with an alcohol swab. Next, abrade the skin with dry gauze or prepackaged pads (Figure 15-28).
Clean, abraded skin provides better contact with the electrodes.
4. Peel the backing from the electrode and check to make certain the electrolyte is moist. Correctly place disposable electrodes on the proper landmarks of the chest according to manufacturer’s directions.
FIGURE 15-28 Prepping the patient’s skin If electrode pads are dried out, you will not obtain a good tracing. Each monitor is slightly different and directions should be followed for the monitor being used.
5. Be sure the electrodes adhere firmly to the skin by applying gentle pressure with your fingers, starting at the center of the electrode and working toward the outer edges.
Good contact with the skin provides an accurate tracing.
6. Connect lead wires to the electrodes. Reinforce the electrodes to the skin with a piece of nonallergenic tape if necessary.
Reinforcing the electrodes with tape helps the electrodes stay on more securely.
7. Instruct the patient to dress and plug the electrode cable into the monitor. Check the recorder by running a baseline test strip. Place the unit on the patient (Figure 15-29).
Running a test strip on the unit will ensure the unit is working properly. FIGURE 15-29 A Holter monitor in place and recording
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RATIONALE
8. Note the start time. Explain the importance of the activity diary to the patient and how to accurately complete all information.
An accurate diary relates patient symptoms with cardiac activity.
9. Specify the exact time the patient should return to the office for removal of the monitor.
The monitor should be removed shortly after completion of the study.
10. Wash your hands and document the procedure in the patient’s chart.
DOCUMENTATION EXAMPLE:
09-03-XX 9:30 a.m.
Holter monitor application per Dr. Beavers. Test strip satisfactory. Instructed patient on proper management of unit and items to enter in activity diary. Pt. instructed to return at 9:30 a.m. on 09-04 for monitor removal. Lillian Kelly, CMA (AAMA)
Chapter Summary Coronary heart disease is the nation’s leading cause of death. The need for cardiac education and monitoring are essential to reduce the risks of death associated with heart disease. A quick noninvasive procedure that can check the heart’s electrical system is the EKG or electrocardiogram. The medical assistant is often responsible for performing different types of cardiac testing including electrocardiography and Holter monitor application and removal. Medical assistants should know how to properly hook the patient up and perform these procedures as well as what a normal tracing should look like. Being familiar with how to recognize artifacts and other factors that can prevent proper measurement will assist the provider in forming an accurate diagnosis.
FIELD APPLICATION CHALLENGE A patient with a history of coronary artery disease presents with complaints of fluttering in the chest, SOB, and an irregular heartbeat. The medical assistant places the patient in an exam room, takes the patient’s blood pressure (130/80) and pulse rate (72 BPM), and alerts the provider. The provider orders a standard resting 12-lead EKG and rhythm strip. The EKG appears normal. However, the provider notices some pauses in the rhythm strip tracing, which are a cause for concern, and asks the medical assistant to repeat the rhythm strip.
1. Which lead should the medical assistant record for the rhythm strip? 2. What are some possible causes for pauses in the tracing? 3. How will the medical assistant keep the patient from becoming alarmed during the second tracing?
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Chapter Assessment 1. The heart is discharging electrical impulses during: a. polarization. b. repolarization. c. systole. d. depolarization. 2. The pacemaker of the heart is the: a. bundle of His. b. SA node. c. Purkinje fibers. d. AV node. 3. The artifact known as somatic tremor is caused by: a. AC interference. b. electrical activity. c. involuntary muscle movement from the patient. d. interrupted baseline. 4. To ensure the EKG machine is measuring accurately it must be standardized: a. daily. b. weekly. c. at the beginning and end of each EKG. d. at the beginning of each lead or group of leads. 5. The gain or sensitivity control that controls the height of a standardization should normally be set on: a. 10. b. 5. c. 20. d. 0. 6. What is another name for the Holter monitor? a. Portable ambulatory heart monitor b. Cardiac monitor c. 24-hour resting EKG d. Monitoring EKG
Web Activities 1. Search the Web for the American Heart Association’s recommendations for good heart health. 2. Find smoking cessation programs in your area for patient referral. 3. Search the Internet for three EKG units manufactured by different companies. List outstanding features of each unit and at least two drawbacks for purchasing the units.
CONNECTION Using your StudyWARE CD-ROM: ❖ Complete the Hangman and Concentration activities for this chapter. ❖ Complete the Quiz for this chapter in Test Mode.
THE DVD LINK On your StudyWARE CD-ROM, go to the DVD Challenge for this chapter. View the DVD clip and respond to the following questions: 1. What did the medical assistant extern do to Mr. Byrne’s chest before placing the electrodes on his chest? 2. Which direction should the tabs face when applying electrodes to the chest and arms? Which direction should the tabs face when applying electrodes to the legs? 3. If the R wave is deflecting off of the graphing paper, you should decrease the gain to _____? 4. If the patient’s heart rate is really fast, you should do what to the paper speed?
C H A P T E R
Pulmonary Examinations and Procedures Chapter Outline Types of Providers Who Specialize in Treating Pulmonary Disorders Respiratory Health Screening Questions Respiratory Examinations Factors That May Increase the Patient’s Risk for Respiratory Disease Smoking Environmental Hazards Contagious Infections Diagnostic Testing Radiological Exams
Bronchoscopy Pulmonary Function Testing Peak Flow Testing Pulse Oximetry Testing Laboratory Tests TB Skin Testing Sleep Apnea Studies Medication Inhalation Therapy Nebulizers Inhalers Oxygen Administration Legal Issues to Consider When Administering Oxygen
16 Essential Terms atelectasis bronchoscopy carcinogen hypoxic induration inhalers Mantoux skin test metered-dose inhalers (MDI) multidrug-resistant TB (MDR-TB) nebulizer oxygen saturation peak expiratory flow (PEF) peak flow meter pleural effusion pulmonary function testing pulmonologist pulmonology pulse oximetry purified protein derivative (PPD) QuantiFERON-TB Gold Test (QFT-G) continues
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KEY COMPETENCIES
CAAHEP
ABHES
Performing a Spirometry Test
III.C.3.b.3.b
VI.A.1.a.4.ee
Obtaining a Sputum Specimen and Preparing a Smear
III.C.3.b.2.c
VI.A.1.a.4.j
Performing Pulse Oximetry
III.C.3.b.4.f
VI.A.1.a.4.h
The Administration of a Breathing Treatment Using a Nebulizer
III.C.3.b.4.g
VI.A.1.a.4.m
sleep apnea spirometer spirometry sputum thoracentesis tuberculosis (TB) vital capacity (VC)
Developmental Objectives After completing this chapter, you should be able to: 1. Correctly spell and define the essential terms. 2. State the name of the physician who specializes in treating diseases and disorders associated with the respiratory tract. 3. List common screening questions that correspond with respiratory disorders. 4. List common environmental factors that increase a patient’s risk for respiratory disorders. 5. List and describe several benefits linked with smoking cessation. 6. List five types of diagnostic tests and three types of laboratory tests that aid in diagnosing respiratory disorders. 7. List and describe the different values associated with pulmonary function testing and explain what “Personal Best” means when comparing results from one individual to another. 8. Describe the role of the medical assistant during PFT testing and explain how this role assists the patient in obtaining the best result possible. 9. Explain the purpose of pulse oximetry testing and record the average SpO2 range for healthy individuals. 10. Describe factors that can interfere with pulse oximetry testing and provide solutions for resolving each factor. 11. Describe two types of medicinal inhalation therapies and describe the types of patients that can benefit from them. 12. List the screening tests that can be performed to assist in diagnosing tuberculosis and list the name of the vaccine that helps prevent tuberculosis.
Introduction Respiratory health is vitally important to the patient’s overall health. If the patient has a breathing disorder, it affects other major organs including the heart and brain. Respiratory conditions that severely obstruct breathing can result in death. The medical assistant must be able to identify life-threatening encounters and institute measures to sustain breathing. Medical assistants are routinely called upon to perform respiratory testing and provide patients with appropriate treatments. Diagnostic procedures may include
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spirometry or pulmonary function testing (PFT), obtaining sputum samples for bacterial cultures, and performing pulse oximetry testing (a measurement of the patient’s blood oxygen saturation level). Patients may also be sent to an outside diagnostic center for more specialized testing. Medical assistants should be familiar with these tests so that they can provide patients with proper instructions for test preparation. Thorough preparation will improve the level of patient compliance resulting in successful and accurate testing. The field of medicine not only deals with treatment of disorders, but also with the prevention of disease. Many environmental hazards institute a negative influence on respiratory health. The medical assistant is often instrumental in providing preventive educational instruction for patients to reduce their risks of future disease.
TYPES OF PROVIDERS WHO SPECIALIZE IN TREATING PULMONARY DISORDERS Medical assistants often perform respiratory procedures in family practice facilities but they may also be called upon to perform more specialized procedures in a specialty practice, such as a pulmonology medicine practice, which involves caring for patients with specific respiratory disorders. A physician who specializes in respiratory care is a pulmonologist. Pulmonary disease is often debilitating and patients may become disabled as a result of their illness. Oxygen intervention is usually necessary in the latter stages of pulmonary disease, forcing the patient into confinement.
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The medical assistant can be instrumental in educating patients on how to prevent such diseases. Many respiratory disorders can be averted by following special preventative procedures.
RESPIRATORY HEALTH SCREENING QUESTIONS Medical assistants may have the responsibility of screening patients prior to provider examination. The depth of screening will be established by office protocol but, in general, medical assistants should be able to ask a series of questions related to the patient’s symptoms. Table 16-1 lists types of questions that are typically asked during respiratory screenings and the common procedures that coincide with symptoms. Important note: Medical assistants should never perform any procedure unless directed to do so by the provider; however, they can set up various equipment and supplies to help save time in the event that testing is ordered.
Respiratory Examinations Medical assistants are generally responsible for obtaining the patient’s vital signs prior to a provider examination. Respiratory rate is included during vital sign assessment, along with blood pressure, temperature, pulse, and pain assessment. The procedures for obtaining vital signs, such as respiratory rate and irregular breathing patterns, are detailed in Chapter 11. The provider may recheck the patient’s breathing, and listen to specific breathing characteristics during the examination portion of the visit. If the provider detects any abnormalities, diagnostic testing may be ordered.
TABLE 16-1 Patient Screening and Instructions for the Respiratory System ASK THE PATIENT: “ARE YOU EXPERIENCING ANY. . .”
Shortness of breath, coughing, bringing up phlegm, wheezing, coughing up blood? Any history of respiratory disease or frequent infections? Do you smoke, if so, how many packs per day? Do you live or work in an environment that makes you vulnerable to certain respiratory conditions or diseases (histoplasmosis, black lung, etc.)?
DISROBING INSTRUCTIONS
Remove all garments from the waist up.
VITAL SIGNS
Temperature, pulse, respiration, blood pressure, pain/breathing rating
EQUIPMENT
Stethoscope, nebulizer, pulse oximeter, PFT equipment
POSSIBLE PROCEDURES
Pulse oximetry, PFT testing, breathing treatments, oxygen therapy
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FACTORS THAT MAY INCREASE THE PATIENT’S RISK FOR RESPIRATORY DISEASE There are several factors that can increase a patient’s risk for respiratory disease. Smoking, environmental factors, and infection can all contribute to chronic respiratory disease.
Smoking The effect of smoke on the lungs, either directly or through secondhand smoke, has been linked to many illnesses and diseases. Figure 16-1 illustrates a patient with emphysema using an oxygen tank in order to breathe. It doesn’t matter whether the smoking products are in the form of cigarettes, pipes, cigars, or even marijuana, they all have a negative effect on health. Even secondhand smoke has a significant impact on health. The American Cancer Society states that a nonsmoker who lives with a smoker has a 30% higher risk of developing lung cancer than those who live in a nonsmoking environment.
Image not available due to copyright restrictions
Smoking is addictive and most smokers need some form of medicinal intervention along with emotional support to quit. The medical assistant may be active in providing patients with information about local organizations that provide smoking cessation courses and a listing of support groups in the area. Nutritional support may be indicated since weight gain is common when patients stop smoking, especially during the early phases of smoking cessation.
Environmental Hazards When conducting respiratory screenings, it is important to gain information regarding the patient’s home
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FI E L D S M A R T S Alarming data shows that lung cancer kills more people than colon, breast, and prostate cancer all combined. It is now the leading cause of cancer death of both genders according to the American Cancer Society (ACS). The ACS predicted that the number of deaths associated with lung cancer would reach over 160,390 in 2007, with the number of women approaching that of men. Factors that may increase the risk for getting lung cancer include: ❖ Smoking (this includes tobacco in all forms, hookah smoking, and marijuana) ❖ Exposure to asbestos ❖ Exposure to radon ❖ Uranium in the workplace ❖ Inhaling chemicals ❖ Diesel exhaust ❖ Radiation therapy ❖ Constant inflammation of the lungs ❖ Talcum powder produced prior to 1973, as it contained asbestos ❖ Family history ❖ Diets low in fruits and vegetables ❖ Air pollution Collecting a good history is important so that providers can be proactive in ordering testing to track potential concerns before they become unmanageable. Additionally, health care workers can provide the patient with education to help prevent or reduce the affects of illnesses that occur as the result of environmental hazards.
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PAT I E N T T U T O R
❖ Minimizing your risks for developing lung cancer, heart attack, stroke, and chronic lung disease ❖ Overall improvement in general health ❖ No longer putting your family or friends at risk with secondhand smoke ❖ No more stains on teeth, hands, and fingers ❖ Avoidance of wrinkles that typically appear as a result of smoking ❖ No more smoke residue on clothing and hair ❖ An improvement in taste and smell senses ❖ An overall improvement in the quality of life
and work environments. Are there hazardous elements in which the patient has frequent exposure? Obtaining travel information upon initial screening might also reveal environmental respiratory hazards. Respiratory disorders may occur when individuals are exposed to asbestos, radon, uranium, arsenic, beryllium, vinyl chloride, nickel chromates, coal, mustard gas, chloromethyl ether, gasoline fuels, diesel exhaust, and lead. These materials are generally considered carcinogens (cancer-causing agents). Wood-burning stoves or fire-
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PA TIEN T P E R SP E C T I V E Wow, the medical assistant is bombarding me with all kinds of information about the hazards of my job. All of this stuff is really scaring me, and I’m not sure what to do. It almost seems like the provider wants me to quit my job, but financially, that’s impossible. Now what should I do?
Once you have made the decision to quit, consider the following: ❖ Join a smoking cessation support group. The American Lung Association offers both educational programs and support groups to assist individuals trying to quit smoking. ❖ Set a date to quit. ❖ Don’t quit during a stressful time. ❖ Exercise every day. ❖ Plan a great nutritional program. ❖ Change your routine when quitting. ❖ Drink plenty of healthy fluids. ❖ Plan some fun activity each day. ❖ Use nicotine replacement such as gums, patches, inhalers, and nasal sprays. These are not as harmful as smoking, if used correctly. They do not have the tars associated with the cigarettes and cigars. ❖ Consider hypnosis, acupuncture, or other complementary alternative measures.
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Smoking cessation is difficult due to the addictive nature of the product. In order to be successful, you must make a conscious decision to take charge of your body and to stop letting the nicotine control you. To stay with the program, continually remind yourself of the benefits of quitting, including:
places are also considered pollutants that might affect respiratory status. Asbestos workers who also smoke may increase their risk of lung cancer by up to 90%. Awareness of these facts may provide the patient the education to utilize safety items at work such as filtered masks.
Contagious Infections Many respiratory disorders are the result of microorganisms that spread from one person to another through inhalation or ingestion. The common cold, influenza, pneumonia, and tuberculosis are just a few communicable diseases that are spread through direct or indirect contact with infected individuals. It is imperative that the medical assistant stress the importance of good infection control with patients, especially during cold and flu season. The Patient Tutor tool box on the next page outlines actions that individuals may take to decrease their risks of infection. Educating patients on how to reduce their risks of infection will help to keep patients from contracting respiratory illnesses that compromise their respiratory health.
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To avoid contracting and spreading a respiratory infection, you should employ the following measures: ❖ Wash hands frequently, especially prior to eating and after going to the restroom. (Alcohol-based cleansers are effective in preventing infection and convenient to use.) ❖ Do not share toothbrushes, eating utensils, lip balms, or drinking glasses with other individuals.
DIAGNOSTIC TESTING A variety of testing measures may be instituted to diagnose respiratory disorders. The type of testing used will be dependent on the patient’s symptoms.
Radiological Exams The typical exam to view the lung is the chest x-ray, seen in Figure 16-2. This type of x-ray may be performed FIGURE 16-2 A chest for a routine exam or during x-ray a preemployment physical. The x-ray can also be used to explore possible illnesses and disorders, including pneumonia, tumors, and atelectasis, that is, a collapse of the alveoli (air sacs within the lungs), rendering them ineffective. Further details involving x-ray examinations are discussed in Chapter 31.
Chest CT Computerized tomography (CT) provides images of the lungs in cross sections as the computer rotates completely around the body. Figure 16-3 shows an example of a CT scan of a lung. Refer to Chapter 31 for a full explanation of a CT scan.
MRI Magnetic resonance imaging (MRI) is a noninvasive diagnostic scan used to render images of the inside of an object. It is most often used in medical imaging to
❖ If you have to cough or sneeze, use a tissue to cover your mouth and nose. This will reduce the number of bacteria in the air and on your hands. ❖ Correctly dispose of tissues. Never lay a tissue on a counter surface or table. Dispose of used tissues immediately.
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PAT I E N T T U T O R
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FI E L D S M A R T S Know the office protocol for reporting diagnostic results to the patient. Does the provider allow the medical assistant to give out negative results before the provider has had an opportunity to review them? Is a follow-up office visit the only means of obtaining the results? In what time span can the patient expect a call? Explaining the diagnostic reporting procedures at the time the procedure is performed will help to alleviate unnecessary worry for the patient.
FIGURE 16-3 A CT lung scan illustrating bubbles (blebs) caused by emphysema. The blebs appear as large dark areas with white borders on the outer edges of the lungs.
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CR ITI C A L TH I N K I N G C H AL LEN G E A patient calls the office wanting to know the results of a chest x-ray. The report states that the lungs are clear and that there are no signs of abnormalities. The provider has not seen the results and is on vacation until next week. The office policy states that results cannot be given to the patient until the provider signs off on them. The patient is upset and wants the results right now. The patient’s brother died of lung cancer last year and the patient is worried because the patient has symptoms similar to those of the deceased brother. 1. Should you give the patient the results? 2. Is it really a big deal since the results are negative? 3. Are there any alternatives for easing the patient’s mind without breaking office policy? 4. What are some possible ramifications of going against office policy?
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dure and the patient’s BP, oxygen saturation levels, and heart are monitored throughout the procedure.
Pulmonary Function Testing There are a few tests that can be performed by the medical assistant in the office to study the effectiveness of the lungs or to help diagnose asthma. One of the most common and easy tests to perform is spirometry testing. Spirometry, or pulmonary function testing, is a noninvasive test that detects the lung’s ability to function. A spirometer (Figure 16-5) is the instrument that measures lung function. It can measure how rapidly a patient can move air in and out of the lungs and how much air is moved in and out of the lungs. Pulmonary testing is performed for a variety of different reasons including to detect lung obstructions, to assess lung health prior to surgery (significant reductions in vital capacity (VC) testing can mean that the patient is more prone to respiratory complications following surgery), and to detect how well certain medications are working. The medical assistant is often responsible for performing spirometry testing and for providing the patient with feedback in order to improve performance during testing. Refer to Procedure 16-1 for a complete procedure for performing a spirometry test.
The Importance of Coaching detect disease or other physiological alterations of living tissue. The MRI gives a clearer picture than traditional x-rays. Problems with patients who suffer from claustrophobia must be considered when ordering this type of examination. Refer to Chapter 31 for further information on MRI studies.
Coaching can be very effective during spirometry testing (Figure 16-6). Patients will often feel discouraged if they don’t perform well during initial testing. The patient, especially when frustrated, might need to be “cheered on” to succeed. The medical assistant might say something like the following to encourage
Bronchoscopy Bronchoscopy is a test used to examine the airway. A bronchoscope (Figure 16-4) is a long flexible tube that is passed through the mouth, down the trachea, and into the bronchi to examine specific structures within the airway. The scope can also be used to remove foreign bodFIGURE 16-4 A bronchoscope ies, identify tumors, (Courtesy of Olympus America, obtain culture mateInc., Melville, NY.) rial, or to obtain tissue biopsies. Biopsies can be performed through the bronchoscope to help in the diagnosis of asthma. The patient is commonly sedated for the proce-
FIGURE 16-5 The spirometer is used to measure lung function.
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C R I T I C A L T H I N K I NG CHALLENGE
FIGURE 16-6 The medical assistant coaches the patient during PFT testing.
Refer to the Patient Perspective tool box on this page, and answer the following questions: 1. Spirometry testing usually involves a minimum of three different tests. It is common for patients to not do very well on the first test or two. What can you say to the patient so that the patient doesn’t feel so discouraged? 2. Why is your coaching so important during the testing? 3. Spriometry is often performed both prior to and following treatment. What type of results would you expect to see following treatment?
the patient during testing: “Blow, blow, blow! Keep going, you can do it!” This may be necessary in order to achieve the best results possible.
Calibrating the Spriometer To make certain that the spirometer is working correctly it should be calibrated on any day that testing is scheduled. Spirometry units usually come with a 3-liter calibration syringe that is used to check the unit’s performance. Three liters of air is injected into the unit from the 3-liter calibration syringe. The results of the calibration should fall within 3% of the 3 liters. The medical assistant should refer to the owner’s manual when ranges do not fall within the accepted range.
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PA TIEN T P E R SP E C T I V E I feel like I am going to pass out. I can’t blow any more than I am already doing. The medical assistant is telling me to breathe harder, but it is too difficult. I feel like I have no air at all in my lungs. I bet the medical assistant thinks I am just really out of shape. The medical assistant keeps repeating the test and looks so disappointed after reviewing the results. I hope there isn’t anything seriously wrong with me!
Understanding the Results The spirometer will typically graph the results and provide the calculations while the provider reviews and interpret the outcomes. Table 16-2 depicts various measurements used in PFT testing.
Normal Results Normal results are influenced by several factors, including the patient’s age, height, and gender. Results are expressed as a percentage of the predicted lung capacity. Expected outcomes are listed below: ❖ Normal PFT outcomes: 85% or higher of the predicted value ❖ Mild disease: 65% to 84% of predicted values ❖ Moderate disease: 50% to 64% of predicted values ❖ Severe disease: Less than 50% of predicted values Another type of pulmonary function test is the exercise challenge test. This test uses spirometry testing prior to and following strenuous activity (using a treadmill or stationary bike). The test correlates any relationship between airflow and activity and assists in diagnosing conditions such as exercise-induced asthma.
Peak Flow Testing If spirometry proves inconclusive, peak expiratory flow (PEF) may be tested with a peak flow meter (Figure 16-7) or monitor. This test is often performed
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TABLE 16-2 Definitions of Measurements from Pulmonary Function Tests Forced expiratory volume after 1 second (FEV1)
The total amount of air forcefully exhaled during the first second of testing. (Patients with healthy lungs should be able to force out 70% to 75% of the air in their lungs within that first second of testing, emphasizing the need for appropriate education and coaching. Any type of a blockage or restriction may cause the result to drop.)
Forced vital capacity (FVC)
The maximum amount of air forced out of the lungs when the patient exhales as rapidly and forcefully as possible into the tube after taking in a deep inhalation (usually expressed in liters).
Tidal volume (Vt)
The amount of air during inspiration and expiration when breathing normally.
Inspiratory reserve volume (IRV)
The additional amount of air a patient could potentially inhale.
Expiratory reserve volume (ERV)
The additional amount of air a patient could potentially exhale.
Residual volume (RV)
The air that is left in the lungs after the patient forcibly exhales all the air the patient can.
Total lung capacity (TLC)
The amount of air the lungs are able to hold.
Vital capacity (VC)
The maximum amount of air the patient is able to inhale and exhale.
Functional residual capacity (FRC)
The amount of air that is left in the lungs after the patient normally exhales.
when there are symptoms of asthma but the patient has normal spirometry results. The device for measurement is disposable and inexpensive, enabling the test to be performed at home over a period of two to three weeks. As PEF varies throughout the day, times for testing must be recorded. The test measures the speed of exhalation with the greatest effort. Peak flow testing is an easy test that can be performed by the patient. A peak flow meter is a small handheld device that measures the fastest speed air can FIGURE 16-7 Examples of peak flow meters
be blown out of the lungs and is a great tool for the patient to monitor lung ailments such as asthma.
Important Guidelines for Using a Peak Flow Meter Some important guidelines when using a peak flow meter include: 1. 2. 3. 4.
5. 6. 7. 8.
Remove all gum and food from mouth. Start pointer on flow meter on 0. Take in a deep breath. Place mouthpiece in mouth behind the teeth, with lips tightly sealed around the tube. Move tongue out of the way. Breathe out as fast and hard as possible. Record the results from the gauge; move it back to 0. Repeat two more times. Record the highest reading of the three attempts.
Significance of a Peak Flow Reading Because everyone has a different lung capacity, everyone has a different “personal best” peak flow reading. The provider will help the patient come up with what is considered a “personal best” reading, based on the patient’s readings in the office and the patient’s personal medical condition. Generally, patients that have a peak flow rating that is 80% or better of their personal
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best are well controlled and do not need immediate treatment. If the reading falls between 50% to 79% of the patient’s personal best, it means that the patient needs to take a quick relief medication. Anything below 50% means that the patient should immediately seek emergency care.
Pulse Oximetry Testing Pulse oximetry is a noninvasive, indirect test that is used to measure pulse rate and oxygen levels in the blood. A pulse oximeter (Figure 16-8) is a device that measures oxygen saturation, abbreviated as SaO2, in the blood. SpO2 is a more accurate abbreviation for oxygen saturation that is measured through pulse oximetry because the blood sample comes from capillary beds in peripheral circulation, not arterial circulation; however, the abbreviation SaO2 may be used as well when recording results from this procedure. The test is performed by wrapping a small strap around the patient’s nail bed on the finger or toe or placing a clip on the bridge of the patient’s nose or earlobe. The probe is two-sided. One side of the probe contains a light-emitting diode (LED) that transmits red and infrared red light through the patient’s tissues to a photo detector located on the opposite side of the probe. A large portion of the light is absorbed by body tissue but a small amount is able to seep through and is detected by the photo detector. Pulse oximetry is not as accurate as arterial blood gases but is very useful in monitoring the patient between arterial blood gases. It is also useful in emer-
FIGURE 16-8 A pulse oximeter
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FI E L D S M A R T S Complications from hypoxia can start when the patient’s SaO2 level drops below 95%. Severe respiratory failure will most likely occur when arterial saturation of hemoglobin falls between 85% and 90%. This is a life-threatening condition. You should alert the provider when SaO2 levels fall below acceptable levels and gather the appropriate oxygen equipment and supplies so that you are prepared when the provider gives the order to administer treatment.
gency situations when arterial blood gases are not an option. Normal SaO2 or SpO2 levels usually fall between 97% and 99%; however, a range of 96% to 100% is considered normal. An oxygen saturation percentage of 100% over a prolonged period of time, however, can cause organ toxicity. Patients are considered hypoxic (oxygen level is low) if their SaO2 drops below 95%. Cyanosis may not set in until the patient’s SaO2 drops below 75%. Pulse oximetry alerts the provider to start oxygen intervention before physiological signs appear, which can decrease complications that arise from hypoxia.
Conditions in Which Pulse Oximetry Is Indicated Pulse oximetry is indicated in any cardiopulmonary event in which oxygen saturation is a factor. Conditions in which SaO2 levels may drop include the following: ❖ Cardiac conditions such as heart attack, congestive heart failure, and coronary artery disease ❖ Any respiratory disorders such as asthma, pneumonia, or congestive heart failure Pulse oximetry may also be used to monitor the effectiveness of oxygen therapy and drug therapy as well as to monitor oxygen saturation procedures during surgical procedures. It is quite often used in ambulatory care, especially in urgent care centers. Oxygen saturation is now considered a vital sign. Medical assistants should do everything possible to ensure accurate readings and should be familiar with readings that indicate immediate intervention.
Parts of the Oximetry Unit Handheld units typically consist of two major parts: the monitor that displays the results and the probe that
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Variables That Can Affect Oximetry Readings
d
e c b
a
FIGURE 16-9 Parts of the pulse oximeter (Refer to Table 16-3 for a description of each part.)
is attached to the patient’s body (see Figure 16-8). The probe may be disposable but quite often is reusable. Nondisposable probes should be disinfected with alcohol or another disinfectant between patients. Parts of the monitor are shown in Figure 16-9 and explained in Table 16-3. The unit should be handled carefully to avoid breakage. For a complete procedure on how to perform pulse oximetry, refer to Procedure 16-2.
There are several variables that can interfere with pulse oximetry readings. The medical assistant must do everything possible to ascertain that readings are accurate. An error in oximetry reading can lead to incorrect treatment, which can cause great harm to the patient. Variables that can affect oximetry readings include: ❖ Ambient lighting: If the room contains bright light, either natural or artificial, that shines directly onto the probe, it can interfere with light absorption and produce a false reading. In order to reduce the risk of an inaccurate reading, the medical assistant can turn down or turn off the lights while performing the procedure, or can shield the probe by covering it with a towel or dry wash cloth. ❖ Callused digit: A callused digit can cause an inaccurate reading due to poor perfusion in the area. Try moving the probe to a digit that is not callused or to an earlobe. ❖ Nail polish and nail overlays: These items can prevent light transmission. Nail polish should be removed from the digit on which the testing is being performed. If the patient has artificial nails, another acceptable location should be selected. ❖ Patient movement: Patient movement may cause the electrode to loosen, making it difficult for the probe to pick up a signal. The patient should be instructed to remain still during testing. If patient movement is unavoidable due to uncontrollable tremors or other factors, the probe should be attached to a site that is not affected by movement such as the earlobe or toes.
TABLE 16-3 Parts of the Pulse Oximeter Monitor Refer to Figure 16-9 for the parts of the oximeter. On-off control (a)
Turns the unit on and off
Low battery indicator (b)
An indicator on the monitor that lets you know when the battery is running low
Pulse strength indicator (c)
Displayed as a set of bars; indicates the strength of the pulse in relationship to the location of the probe
SpO2 display (d)
Displays the patient’s oxygen saturation level
Pulse rate display (e)
Displays the patient’s pulse rate
Volume control (not pictured)
Adjusts the sounds of the heartbeat coming from the monitor; usually has three settings: low, high, and off
Alarm (not pictured)
Indicates a problem with the unit or patient and should not be ignored
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❖ Dried blood, dirt, or oil: These items can interfere with light absorption. Make certain that the site is cleansed prior to probe application. ❖ Applying the probe on an extremity with poor perfusion: If the patient’s digit is cold or there is vasoconstriction in the area, you will not get an accurate reading. Have the patient warm the hands prior to testing or select a site where perfusion is better.
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P A T I E N T P E R S P E CT IV E I can’t believe that the medical assistant wants to stay in the room with me as I collect this sputum sample. This procedure is very embarrassing. I wish I could ask the medical assistant to leave.
Laboratory Tests Other methods used to diagnose respiratory disease include examination of sputum, blood, and other fluids from the respiratory tract. Often medications are prescribed based on the results of laboratory tests. The medical assistant must be able to obtain these specimens while maintaining the highest level of infection control in order to prevent the spread of communicable disease.
A type of sputum smear, the KOH test, is important in testing for fungal microorganisms in the respiratory system. Patients should be told not to use any mouth rinses prior to testing that contain antibacterial agents, as this could interfere with test results. The patient should be encouraged to drink lots of fluids prior to testing to help liquefy the mucus for easier expectoration. Following the test, the medical assistant may want
Sputum Tests The medical assistant will be responsible for obtaining a sputum specimen for a culture or a smear. Sputum is a fluid that is produced in the lungs and bronchi. A sputum culture is obtained to test for bacteria, blood, or abnormal cells, which can assist in the diagnosis and treatment of various pulmonary disorders.
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F IEL D S M A R T S Patients who have elevated levels of carbon monoxide in the bloodstream may have falsely elevated oxygen saturation levels. Carbon monoxide turns arterial blood bright red, which can trigger the pulse oximeter to display elevated SpO2 readings. Patients who smoke usually have higher levels of carbon monoxide in the blood due to the presence of carbon monoxide in the cigarettes; therefore, oximetry readings on smokers should be followed up with arterial blood gases when possible. Medical documentation should state the time of the patient’s last cigarette, prior to testing. In cases where the patient recently smoked and blood gases are not an option, the provider may want to follow up with SpO2 readings performed at different time intervals or with continuous monitoring.
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C R I T I C A L T H I N K I NG CHALLENGE Review the Patient Perspective tool box on this page. 1. Would it be appropriate for you to leave the room while the patient collects the sample? 2. List the pros and cons of your staying in the room while the sample is being retrieved.
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PATIENT TUTOR Patients should be educated on the differences between sputum and saliva or spit. Saliva or spit is the liquid secretion that is normally in the mouth and may be mixed with secretions from the upper airway or food. Sputum, the material that is needed for testing, comes from deep in the bronchi or lung and is usually brought up through the respiratory tract and into the mouth through deep coughing.
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to offer the patient something to drink to rinse out the mouth. The KOH sputum smear is prepared with potassium hydroxide and may be observed in the office under a microscope. If the office does not have in-house laboratory facilities, it is important for the medical assistant to correctly request a KOH smear if ordered, in place of, or in addition to, a sputum culture. Refer to Table 16-4 for a list of diseases that can be diagnosed with the aid of a sputum culture or KOH smear.
Thoracentesis
Arterial Blood Gases
TB Skin Testing
Although the medical assistant will not be responsible for obtaining an arterial blood sample, some patient instruction and preparation for testing may be indicated. Arterial blood gases, ABGs, are ordered and studied for two general reasons:
Tuberculosis (TB) is an infection caused by Mycobacterium tuberculosis, a slow-advancing bacterium. This bacterium is most frequently seen in the lung, but may also be present in other parts of the body that are rich in blood and oxygen. These areas include the lymph nodes, joints, kidneys, spinal meninges, liver, and tissues lining the abdomen. The bacteria can travel throughout the bloodstream. Symptoms related to the lung include:
❖ To evaluate the health of the respiratory system ❖ To study the effectiveness of oxygen therapy The results of the analysis will measure blood pH, along with the amount of O2 and CO2 in the blood. Altitude can affect the sample as “normals” change at higher altitudes. Abnormal results might indicate respiratory stress, renal disorders, or even a head injury, which might affect the respiratory system. Arterial blood gases are drawn from an artery instead of a vein and are usually performed by respiratory therapists or other providers. Blood gases are frequently drawn while the patient is in an inpatient facility such as a hospital, but may also be drawn in the patient’s residence when the patient is nonambulatory. Arterial blood gases are considered to be a more accurate measurement of oxygen saturation than pulse oximetry. When saturation levels are dangerously low, ABGs should be the preferred testing for oxygen saturation due to the severity of the patient’s condition.
TABLE 16-4 Diseases and Disorders That May Be Diagnosed with the Aid of a Sputum Culture or KOH Sputum Smear SPUTUM CULTURE
KOH SPUTUM SMEAR
Bronchitis
Histoplasmosis
Tuberculosis
Coccidiodomycosis
Pneumonia
Blastomycosis
Thoracentesis (Figure 16-10) is a medical procedure used to withdraw fluids from the pleural space. This excess fluid is referred to as a pleural effusion. The test is performed by a provider, usually following a chest x-ray indicating excess fluid accumulation. Following injection of an anesthetic agent, a needle is inserted into the lung and the fluid is aspirated by syringe and transferred to a sterile container. The fluid is then analyzed at the laboratory.
❖ ❖ ❖ ❖
Cough with bloody sputum Night sweats Tachycardia (rapid heart rate) Swelling of lymph nodes in the neck
Transmission occurs only if a person has active TB, not latent TB, which cannot be spread but can turn into active TB if not treated. Even though TB can be spread through droplets, a single exposure to the
FIGURE 16-10 Thoracentesis is performed to remove fluid from the pleural cavity.
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droplets is usually not capable of promoting disease. Repeated exposure to an infected individual, however, increases a person’s risk of contracting the disease. This is the reason that the disease is so prevalent in prisons, homeless shelters, and other crowded institutions. Of course, anyone with a weakened immune system is more susceptible to TB, including AIDS patients, senior adults, and malnourished individuals. According to the Centers for Disease Control and Prevention (CDC), tuberculosis is responsible for more deaths than any other communicable disease in the world. Approximately one-third of the world’s population has some form of TB. Tuberculosis outbreaks declined for several years following the first half of the 19th century but started regaining momentum in the mid-1980s and 1990s, causing an alarming increase in the number of people acquiring the disease. Some factors that may have contributed to the increase include: ❖ The AIDS epidemic, which came on the scene around the time the increases started ❖ An increase in poverty, malnutrition, and crowded conditions within the United States and abroad ❖ Lack of health care in third-world countries ❖ An increase in immigration and the number of people traveling to other countries ❖ An increase in drug-resistant strains of TB TB is becoming more difficult to treat due to the different strains that are resistant to typical TB medications. Even more alarming are the strains that are resistant to two or more drugs typically used to treat tuberculo-
sis, a condition referred to as multidrug-resistant TB (MDR-TB). Individuals with this condition are highly contagious and are capable of transmitting this form of TB to other individuals. Because health care workers have a greater risk of exposure, they must remain current in their self-testing for tuberculosis. A medical assistant may be responsible for annual testing of office employees, including providers. Positive testing may require a chest x-ray for verification and treatment. A common screening test for tuberculosis is the Mantoux skin test which uses TB antigens called purified protein derivative (PPD). A small premeasured amount of the antigen is injected just under the skin (intradermally), usually on the forearm. A wheal is formed at the injection site (Figure 16-11a) and the area is evaluated somewhere between 48 and 72 hours upon receiving the derivative. A positive reaction will usually result in induration (a degree of hardening of normally soft tissue in the area). The reaction is measured in centimeters (Figure 16-11b). A set of measurement criteria is used based on the person’s risk factors to determine if the test is positive or negative. Unfortunately, this test cannot distinguish if the infection is active or latent, so if a patient has previously had the disease or been exposed to the disease, the patient will usually have a positive result. Individuals with positive results will need to follow up with a chest x-ray. A rather new screening test for TB is a blood test called the QuantiFERON-TB Gold Test (QFT-G). It can be used to help confirm or rule out a latent or active
FIGURE 16-11b The area should be inspected and the amount FIGURE 16-11a A raised wheal should form when you administer the PPD extract if the test is performed correctly.
of induration should be measured. (Only measure the area that is elevated and swollen, not the entire area of erythema or redness.)
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tuberculosis infection. The only problem with this test is that the blood has to be tested within 12 hours of collection, which is not realistic for most practices. There is a vaccine for TB called Bacille CalmetteGuérin (BCG). This vaccine is not widely used in the United States, but is often given to infants and small children in other countries where TB is common.
Sleep Apnea Studies The term sleep apnea refers to periods of breathing cessation during hours of sleep. While there are three types of sleep apnea (obstructive, central, or mixed), this text will focus on the most common type, obstructive sleep apnea. When a person lies down to sleep, the muscles of the throat and the tongue relax, which can partially block the airway. The major symptom of this disorder is loud snoring. A person with sleep apnea may also feel very sleepy during the day even after a full night’s sleep. When a patient stops breathing during sleep, it reduces the amount of oxygen in the blood, which, over time, can lead to serious complications such as high blood pressure, heart attack, or stroke. Sleep apnea is normally diagnosed through a sleep study, which takes place at a sleep center. Electrodes, placed on the patient’s scalp and other locations of the body, are hooked up to equipment that record the patient’s breathing, heart rate, and eye movements while sleeping. The recording is then evaluated by a sleep specialist and a treatment plan is implemented if sleep apnea is detected. Mild forms of sleep apnea may be treated by instituting a weight loss program for the patient, while moderate to severe cases are treated with a device known as a CPAP (continuous positive airway pressure) machine that keeps the airway open during sleep.
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MEDICATION INHALATION THERAPY There are two forms of therapy in which medications are delivered to the lungs: nebulizers and inhalers.
Nebulizers Nebulizers (Figure 16-12) are units that change liquid medication into an aerosol mist so that it can be inhaled through a mouthpiece or face mask. Nebulizers are used for the treatment of asthma and other lung conditions. Common types of medications delivered through a nebulizer include anticholinergics, bronchodilators, and corticosteroids. Nebulizers consists of four major components: ❖ Compressor: Converts the liquid into a mist and powers the nebulizer ❖ Nebulizer tubing: Connects the mouthpiece to the compressor ❖ Medication cup: Houses the medication ❖ Mouthpiece or face mask: Delivers the medication into the patient’s respiratory system Nebulizers can be used both in the office and at home. Breathing treatments typically last 15 to 30 minutes. The prescribed medication is properly prepared and poured into the medication cup. The lid is placed and tightened onto the medication cup and connected to the mouthpiece. The opposite side of the medication cup is connected to the tubing, which is then connected to the compressor. The patient is instructed to place the mouthpiece between the teeth and to purse the lips around the mouthpiece. The patient
FIGURE 16-12 A nebulizer is used to administer breathing treatments.
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F IEL D S M A R T S Patients who have received the BCG vaccine will usually produce a positive reaction to the Mantoux or PPD test. These patients and any other patients who have previously tested positive will need to have a chest x-ray in lieu of the antigen/ antibody testing for future screenings.
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is encouraged to take in deep breaths lasting two to three seconds throughout the treatment. Once there is no aerosol being produced, the treatment is stopped. Patients should be encouraged to take in deep breaths and cough following the treatment to loosen the secretions. Refer to Procedure 16-4 for a procedure on how to administer a nebulizer treatment.
Inhalers Inhalers are handheld portable devices that deliver medication directly to the lungs. There are two basic types of inhalers:
Image not available due to copyright restrictions
❖ Metered-dose inhalers (MDI) (Figure 16-13): These inhalers use a chemical propellant to push the medication out of the inhaler. The medication is delivered to the patient’s lungs by direct inhalation or by squeezing the canister. Squeezing the top of the
canister converts the medication into a fine mist. These inhalers require the patient to squeeze the canister and inhale at the not available due to same time. Some patients Image copyright restrictions find this difficult. The dry power inhalers might be a better choice for those patients. ❖ Dry powder inhalers (Figure 16-14): This type of inhaler does not use a chemical propellant to push the medication out of the inhaler so the patient has to take in rapid inhalations to receive the medication. Patients who perform in-home nebulizer treatments or who use inhalers should routinely check their peak flow readings. Readings should be performed a minimum of two to three times per week and any time the patient has symptoms. Peak flow measurements should be documented both before and following nebulizer and inhaler treatments.
Patients should be instructed how to use a metered dose inhaler (MDI) using the following steps: 1. Wash your hands very well before starting the procedure. (Bacteria on the hands can be transferred to the mouthpiece or medication cup and delivered into the lungs.) 2. Remove the cap and hold the medication in an upright position. Shake the canister well to properly mix the medication. 3. Open your mouth and hold the canister approximately 1 inch from your mouth. (The gas propellant in the canister can cause the medication to bounce off the throat and into your mouth instead of propelling down toward the lungs.) A spacer, which is a short tube that attaches to the inhaler, may be used to assist with the delivery of the medication. A spacer keeps the medication in the plastic tube for a few seconds following depression so that you have more time to inhale.
4. If not using a spacer, press down on the inhaler one time while breathing in slowly through your mouth. If using a spacer, depress the inhaler and wait a few seconds before inhaling slowly through your mouth. 5. Breathe in slowly for three to five seconds. After breathing in the medication, hold your breath for a total of 10 seconds to allow the medication to reach the lungs. 6. Repeat steps 2 to 6 until the prescribed amount of puffs have been delivered. (You should wait approximately 1 minute between each puff.) 7. Only take the prescribed amount of medication. Taking more medication than prescribed can cause serious side effects. If you start to feel a tingling sensation in your hands and feet or start to feel light-headed, you probably took too much medication and should call the physician right away. If the attack is not relieved by the prescribed number of doses, you should call the EMS.
TOOL BOX
PAT I E N T T U T O R
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OXYGEN ADMINISTRATION Oxygen is a colorless, odorless gas that is essential to life. The air that we breathe contains approximately 21% oxygen. Normal oxygen saturation levels range between 96% and 100%; however, a continuous oxygen level saturation of 100% can cause organ toxicity. If oxygen levels drop in the blood, it’s difficult for the tissues of the heart to keep pumping. Oxygen therapy is indicated in conditions where the oxygen saturation falls below an acceptable range, usually below 96%.
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Even though oxygen is considered a gas, when it is administered to supplement what is normally taken in by atmospheric air, it is considered to be a drug. The medical assistant may be responsible for gathering the equipment for oxygen therapy (Figure 16-15) and may even be responsible for administering oxygen in some practices (Figure 16-16); however, the provider or nurse in the practice is usually responsible for the actual administration of oxygen.
Legal Issues to Consider When Administering Oxygen Because every state has its own guidelines for medication administration, including oxygen delivery, medical assistants should check the law in the state in which they are employed to determine if they are able to administer oxygen. Some states are very specific about medication administration, while others are vague. When in doubt, check with the AAMA or AMT for specific guidelines.
FIGURE 16-15 Examples of two different oxygen tanks
Gauge
FIGURE 16-16 A patient receives oxygen. Gauge Large tank in carrier
Small portable tank
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PROCEDURE 16-1 Perform a Spirometry Test Objective: To obtain an accurate spirometry reading to evaluate respiratory health and to evaluate medication effectiveness.
Equipment/Supplies: ❖ Spirometer ❖ Disposable mouthpiece ❖ Disposable nose clips
❖ Disposable tubing ❖ Spirometer calibration syringe ❖ Patient’s chart
PROCEDURAL STEPS
RATIONALE
1. Wash your hands and gather the equipment. 2. Calibrate the machine following the manufacturer’s instructions.
Calibrating the unit will help to ensure that the machine is working properly.
3. Greet and identify the patient using two identifiers.
Identifying the patient will help to reduce the risk of performing the wrong treatment on the wrong patient.
4. Introduce yourself and explain the procedure (Figure 16-17a).
Explaining the procedure helps the patient know what to expect and assists the patient in performing her part of the procedure accurately.
5. Measure the patient’s height and weight if not already performed.
This information must be entered into the unit before testing can be performed. (It assists with setting the parameters for expected outcomes.)
6. Have the patient remove constricting clothing, such as belts and sports bras.
Patient comfort will eliminate any constriction that might alter results due to impaired breathing.
7. Position the patient so that the patient is comfortable and safe.
Seating is recommended in case the patient becomes dizzy or faints.
8. Program the unit with the patient’s information. Information may include: the patient’s name, sex, height, weight, and medication information.
Plugging in this information helps to set the parameters for expected outcome.
9. Place the nose clip on the patient’s nose.
This will prevent air escaping from the nose, which can cause an inaccurate reading.
FIGURE 16-17a Explain the procedure before it begins to obtain the best results.
FIGURE 16-17b The patient should
FIGURE 16-17c Instruct the patient to
be instructed to take the deepest breath possible prior to sealing the lips around the mouthpiece.
tightly seal the lips around the mouthpiece of the spirometer tube so that no air escapes.
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10. Have the patient inhale as deeply as possible (Figure 16-17b) and place the mouthpiece in the mouth. Seal with lips (Figure 16-17c). If the patient has dentures, they are to be left in.
The mouth must be sealed so air does not escape through the lips. This would invalidate the results.
11. Have the patient exhale as hard and long as possible. (Press the start button according to manufacturer’s instructions.)
It is important to coach the patient during this part of the procedure. For example, “Come on, Mrs. Jones, you can do it, keep it going. Blow . . . blow . . . blow.”
12. Repeat the test two more times. Record the results from the spirometer and attach the printout to the chart.
Three times show that the results are reproducible, which is a criterion for accuracy.
13. If ordered, provide medication to the patient.
This test is often used to evaluate the effects of asthma treatments. The test is performed before and after medication for evaluation.
14. Repeat the spirometry procedure, if ordered. 15. Document or attach the results. 16. Discard the test products and clean the equipment.
Use recommended precautions with cleaning equipment or discarding in order to prevent contamination.
DOCUMENTATION EXAMPLE:
10-14-XX 1430
Wt. 125 lbs. Ht. 66 ⬙T98.8, P 92, R20, BP 142/88: Spirometry testing per Dr. Wong. Dr. Wong ordered inhalation therapy after viewing results: Three puffs of Ventolin administered one minute apart. Spirometry testing repeated. Patient tolerated well. Dr. Wong given the results once again. Results normal. Jacob Green, CMA (AAMA)
PROCEDURE 16-2 Perform Pulse Oximetry Objective: To correctly apply a pulse oximeter to the patient and obtain an accurate reading.
Equipment/Supplies: ❖ Pulse oximeter unit/finger probe ❖ Nail polish remover (if indicated)
❖ Cottonball ❖ Soap/towel
PROCEDURAL STEPS
RATIONALE
1. Identify the patient using two identifiers, and introduce yourself. 2. Wash your hands and explain the procedure. 3. Have the patient remove nail polish, if necessary, and wash the hands. Hands should be rinsed well and dried to remove soap and water from the hands.
Washing the hands will remove any lotions or grease that could interfere with the results. Nail polish can also interfere with the results. continues
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PROCEDURAL STEPS
RATIONALE
4. Apply the pulse oximeter probe (Figure 16-18) and observe the perfusion indicator. Observe both the heart rate and the SpO2 levels.
Make certain that you obtain a proper reading. If the probe is not attached correctly, the unit will not work.
5. Leave the oximeter probe attached to the patient and give the findings to the provider. If the saturation rate is below 95%, notify the provider as soon as possible.
An oxygen saturation below 95% can cause harm to the patient.
6. Continue to monitor as long as the provider wants the patient monitored. (The patient may need to receive oxygen if oxygen is poor.)
If the patient is in respiratory distress, the oximeter probe will remain in place until all symptoms are resolved.
FIGURE 16-18 The medical assistant places the pulse oximeter probe on the patient’s finger.
7. Remove the probe once the provider orders the probe to be removed. 8. Record the results in the chart and assist the patient.
DOCUMENTATION EXAMPLE:
02-14-XX 1415
Pulse oximetry per Dr. Simon. Patient washed hands prior to application. Hands completely dried. Applied unit to pt.’s right 3rd digit. Pulse rate: 98, SpO2 96%. Informed provider of results. Ulisha Thompson, CMA (AAMA)
PROCEDURE 16-3 Obtain a Sputum Specimen and Prepare a Smear Objective: To instruct and assist the patient on obtaining a viable sputum specimen that is free of saliva and obtained from deep coughing.
Equipment/Supplies: ❖ ❖ ❖ ❖ ❖
Sterile sputum cup with lid Gloves Mask Waterproof gown Goggles
❖ ❖ ❖ ❖
Cup of water Specimen cup with requisition form Microscopic slide Potassium hydroxide (KOH)
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PART A–OBTAINING A SPUTUM SPECIMEN PROCEDURAL STEPS
RATIONALE
1. Assemble the equipment and properly label the specimen container.
The patient’s name and birthdate should be on the cup.
2. Identify the patient using two identifiers, introduce yourself, and explain the procedure.
You want to make certain that you have the correct patient. Explaining the procedure will help the patient in attaining a proper specimen on the first try.
3. Wash your hands and put on all of your PPE.
The patient sometimes will throw up as a result of obtaining the specimen. The PPE is to protect you from splatter.
4. Have the patient rinse out the mouth.
This will get rid of any residual food in the mouth.
5. Carefully remove the lid from the specimen cup and place on the counter without contaminating it.
Contaminating the lid can ruin the test.
6. Instruct the patient to take in three deep breaths and to start forcefully coughing (Figure 16-19a).
Deep coughing will produce a better specimen.
7. Ask patient to expectorate into the center of the specimen container (Figure 16-19b).
This keeps the secretions from running down the sides of the container.
8. Place the lid on the container without contaminating it and tighten it securely. Place it in a plastic bag. 9. Insert the completed lab slip and send to the lab for analysis.
FIGURE 16-19a The patient is instructed to take three deep breaths before beginning the collection.
FIGURE 16-19b The patient should expectorate directly into the cup and avoid contaminating the inner portion of the cup with the mouth or fingers.
Make sure the lab request name matches the specimen cup for accuracy. Include the appropriate diagnosis codes so that the results will be as expedient as possible.
PART B–PREPARING THE SMEAR (If the provider orders a smear to be made with the specimen)
PROCEDURAL STEPS
RATIONALE
1. Wash hands, apply PPE, and label the slide. Smear the sputum on a microscopic slide.
This will be used to observe possible fungal cells in the sputum.
2. Squeeze one drop of potassium hydroxide over the smear and place a cover slip over the smear.
The potassium hydroxide assists with identifying specific types of fungus. continues
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PROCEDURAL STEPS 3. Place the slide under the microscope on low power for the provider.
RATIONALE This is done so the provider can identify the microorganism.
4. Clean the area and remove PPE. Throw PPE into biohazard container.
DOCUMENTATION EXAMPLE:
1-3-XX 1000
Sputum specimen obtained for a KOH per Dr. Stevens. Substantial amt. blood mixed with sample. Delivered to lab with request. Jessica Hunnicutt, CMA (AAMA)
PROCEDURE 16-4 Administer a Nebulizer Treatment Objective: To correctly set up the nebulizer unit, select the correct medication, and administer a breathing treatment using a nebulizer.
Equipment/Supplies: ❖ Nebulizer ❖ Disposable mouthpiece or face mask ❖ Disposable connecting tubing
❖ Disposable medication dispenser ❖ Medication/diluent (if applicable) ❖ Patient record
PROCEDURAL STEPS
RATIONALE
1. Prepare the equipment.
Plugging in the nebulizer before beginning the procedure will save time.
2. Identify the patient using two identifiers, introduce yourself, and explain the procedure.
It is important to establish that you have the correct patient for safety reasons. Explaining the procedure promotes better compliance.
3. Wash your hands and put on gloves.
This step decreases the spread of germs.
4. Check order (three times) and pour the correct amount of medication and diluent into the medication dispenser. Screw the lid on the dispenser and gently mix the medication (Figure 16-20).
It is important to make certain that you have the correct medication and that it was mixed correctly to avoid complications.
5. Connect the medication dispenser to the mouthpiece or face mask. 6. Connect the disposable tubing to the medication dispenser and nebulizer.
FIGURE 16-20 The medical assistant pours the medication for the breathing treatment into the medication cup.
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RATIONALE
7. Place the patient in a full Fowler’s position or upright position.
This is to help the medication disperse correctly.
8. Turn the nebulizer on. When you turn the nebulizer on, you should see a mist.
The mist will show you that the nebulizer is working properly.
9. If using a face mask, place it over the patient’s face so that it fits comfortably. If using a mouthpiece, instruct patient to place it in the mouth between the teeth and to purse the lips over the mouthpiece making a seal.
The mouthpiece or face mask has to be applied properly in order for the patient to get the full effect of the medication.
10. Instruct the patient to take in slow deep breaths (Figure16-21) that last anywhere from two to three seconds.
This helps the medication to disperse throughout the respiratory tract.
11. Continue treatment until the mist disappears.
When the mist disappears it means the medicine has been used up.
12. Turn off the nebulizer and remove and dispose of the mouthpiece or face mask, medicine dispenser, and tubing into the biohazard trash can.
This step stops the spread of infection.
13. Instruct the patient to take in several deep breaths and to try and cough up any secretions that were loosened during the treatment.
Bringing up the secretions will help clear the obstruction.
FIGURE 16-21 The patient is instructed to take in slow deep breaths during the treatment.
14. Wash your hands and document the procedure. 15. Give the patient home care instructions.
Patients will usually need to be instructed on home care instructions to assist them in getting better.
DOCUMENTATION EXAMPLE:
12-12-XX 1800
Nebulizer treatment, Albuterol , 2.5 mg per Dr. Jones. Pt. tolerated procedure well. Following treatment patient brought up some mucus secretions that were white and tinged with a bit of green mucus. Pt. reported feeling much better following the treatment. Provider followed up with pt. Jay Craig, RMA
Chapter Summary Respiratory health is vitally important to overall health and life processes. The medical assistant has many responsibilities regarding respiratory patients including taking respirations, performing various forms of respiratory testing, and performing treatments. Education is an important tool for disease prevention and management. Medical assistants must continually update their knowledge regarding disease and treatment so that they can better serve their provider and patients.
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FIELD APPLICATION CHALLENGE A 23-year-old patient from another country just recently came to the United States. The patient is excited, having just been accepted to medical school. The patient is required to have a PPD test prior to entrance into the college. You perform the test and the patient returns two days later. The test site is very swollen. The provider looks at the site and states that the test is positive.
1. What could be some possible contributors for the positive reaction? 2. What type of treatment would be indicated for this patient? 3. Why is TB skin testing not an option for this patient in the future? What other testing might the patient have done in the future?
Chapter Assessment 1. Common testing procedures for the diagnosis of tuberculosis include: a. Mantoux testing. b. vital capacity. c. both of the above. d. none of the above.
5. A patient with asthma should perform peak flow readings: a. routinely two to three times per week. b. whenever symptoms occur. c. prior to and following inhalation therapy. d. all of the above.
2. A procedure that involves looking through a flexible tube to visualize the lungs is called: a. colonoscopy. b. x-ray. c. MRI. d. bronchoscopy.
6. A rather new screening test for TB is a blood test referred to as: a. QFT-G. b. PPD. c. TB Skin. d. G-FQT.
3. Spirometry is used to: a. obtain a blood specimen. b. help diagnose asthma. c. study the effectiveness of the lung. d. all of the above. e. b and c only.
7. Variables that can affect pulse oximetry testing include: a. nail polish. b. dried blood. c. patient movement. d. all of the above.
4. A treatment in the form of a mist that uses medications to help open up the airways is referred to as: a. spirometry. b. pulse oximetry. c. nebulizer treatment. d. oxygen therapy.
8. The part of the pulse oximeter that displays the patient’s oxygen saturation level is: a. SpO2 Display. b. ApO2 Display. c. OpP2 Display. d. none of the above.
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Web Activities 1. Visit the Web site for the National Institute for Allergy and Infectious Disease, www.niaid.nih.gov, for information on allergies and infectious diseases. Review the allergy information and formulate a patient education brochure for patients with allergies. Search other Web sites to determine which items trigger allergies in your region. 2. Visit the Web site for the American Cancer Society (www.cancer.org). List the recommendations for lung cancer screening and prevention. 3. The Centers for Disease Control and Prevention Web site, www.cdc.gov, discusses communicable
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diseases. Review the recommendations for flu prevention and flu vaccines. Stay current with communicable diseases in your area. Explore the latest information on anthrax exposure.
CONNECTION Using your StudyWARE CD-ROM: ❖ Complete the Flash Cards activity for this chapter. ❖ Complete the Crossword Puzzle activity for this chapter. ❖ Complete the Quiz for this chapter in Test Mode.
C H A P T E R
Women’s Health Issues: Obstetrics and Gynecology Chapter Outline Types of Providers Who Specialize in Treating Diseases and Disorders of the Female Reproductive System Patient Screening for the Female Reproductive System Gynecology The Menstrual Cycle Menopause The Gynecological Exam General Medical Assisting Duties Mammography and Breast Exam The Pelvic Exam Bimanual Pelvic Exam Rectal Exam
Gynecological Diagnostic Tests and Procedures Sexually Transmitted Diseases Obstetrics Prenatal Care The Initial or First Prenatal Exam Return Prenatal Visits Prenatal Diagnostic Tests and Procedures Ultrasound Amniocentesis Pregnancy Complications Labor and Delivery Postnatal or Postpartum Period Six Week Postpartum Visit
17 Essential Terms abortion amenorrhea amniocentesis atypical Braxton-Hicks contractions cesarean section (C-section) colposcopy cytology dilation dysmenorrhea eclampsia ectopic effacement gestation gravida lochia meconium menarche menopause menses menstruation continues
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ABHES
Assisting with a GYN Exam and Pap Test
III.C.3.b.1.d III.C.3.b.1.e III.C.3.b.4.e III.C.3.b.2.c
VI.A.1.a.4.h VI.A.1.a.4.j VI.A.1.a.4.q VI.A.1.a.4.r
Instructing a Patient in Breast Self-Examination
III.C.3.c.3.c.
VI.A.1.a.7.c
Assisting with the Prenatal Exam
III.C.3.b.4.e
VI.A.1.a.4.h
metrorrhagia miscarriage para parturition perimenopause postpartum preeclampsia prenatal puerperium sexually transmitted disease (STD) toxemia trimester
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Developmental Objectives After completing this chapter, you should be able to: 1. Correctly spell and define the essential terms. 2. Explain the phases of the menstrual cycle. 3. List the parts of a thorough GYN exam. 4. Explain the medical assistant’s responsibilities before, during, and after the GYN exam. 5. Explain the importance of BSE and regular mammography for females over 40. 6. Describe the difference between the direct method and the liquid prep Pap test. 7. Explain the different classes of Pap test results. 8. Describe the bimanual exam. 9. Describe five of the sexually transmitted diseases discussed in this chapter. 10. List and describe seven diagnostic tests and procedures that evaluate the structures of the female reproductive system. 11. Discuss the pros and cons of HRT during menopause. 12. List the recommended schedule for prenatal visits. 13. List and explain each part of the initial prenatal exam. 14. List and describe the rationale for each of the prenatal lab tests performed throughout pregnancy. 15. Explain the uses of ultrasound during pregnancy. 16. Describe an amniocentesis procedure. 17. List and explain the stages of labor. 18. Explain the importance of the postpartum exam. 19. List and describe different methods of contraception. 20. List possible causes for infertility in both the male and the female. 21. Describe possible treatment options for infertility.
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Introduction The field of obstetrics and gynecology (OB-GYN) has many facets. Tracking a patient through the prenatal period can be very exciting. Watching the joy on an expectant mother’s face when you confirm her deepest desire is priceless; but the field of OB-GYN has its downfalls as well. Some patients are saddened by the news that they are expecting a baby due to financial constraints or a lack of support from loved ones. Some expectant mothers end up losing their babies or learn that their unborn baby has a congenital or hereditary defect that cannot be corrected through surgical intervention or medical treatment. The gynecological side of OB-GYN involves regular screening exams by the provider and a myriad of opportunities to educate patients about disease prevention and management. The medical assistant is often the health care professional responsible for providing the patient with educational materials and teaching the patient how to perform breast self-exams. This chapter will help prepare you to work in an OB-GYN practice and will assist you in learning common instruments and tray setups used in the specialty. Additionally, this chapter will prepare you to assist the provider with common OB-GYN procedures and provide you with tips for educating your patients.
TYPES OF PROVIDERS WHO SPECIALIZE IN TREATING DISEASES AND DISORDERS OF THE FEMALE REPRODUCTIVE SYSTEM An OB-GYN is a physician who specializes in diagnosing and treating diseases of the female reproductive system and breasts, and caring for a woman while she is pregnant. The “OB” portion of the term is the abbreviation that is used for obstetrics and is the branch of medicine that involves caring for a woman while she is pregnant. Some physicians, especially those close to retirement age, may cease to care for obstetric patients and will only practice the gynecology side of OB-GYN medicine. An infertility specialist is a physician who specializes in assisting patients that are experiencing problems with conceiving. Medical assistants may work in either specialty.
PATIENT SCREENING FOR THE FEMALE REPRODUCTIVE SYSTEM Medical assistants may have the responsibility of screening patients prior to provider examination or over the telephone. The depth of screening will be established by office protocol, but in general, medical assistants should be able to ask a series of questions related to the patient’s symptoms. Table 17-1 lists types of questions that are typically asked during a GYN screening and lists common procedures that coincide with symptoms. Important note: Medical assistants should never perform any procedure unless directed to do so by the provider; however, they can set up various equipment and supplies to help save time in the event that testing is ordered.
GYNECOLOGY The “GYN” portion of OB-GYN medicine focuses on treating diseases and disorders of the female reproductive system and the breasts. One of its main emphases is on disease prevention and early detection. Many diseases can be prevented with proper education while other diseases can be cured if discovered in the earlier stages. A thorough gynecological history is essential when caring for GYN patients. The patient’s personal and familial history plays a big role in determining the time intervals between particular types of screenings and the type of education given to the patient.
THE MENSTRUAL CYCLE Each month, the endometrial lining (inner lining of the uterus) prepares to receive and nourish a fertilized ovum (egg). If fertilization does not occur, the lining deteriorates and flows out of the body; a process known as menses or menstruation. A woman’s first menstrual cycle is referred to as menarche and usually occurs somewhere between the ages of 11 and 15. The monthly cycle continues for approximately 35 years until complete cessation occurs, a process referred to as menopause. A menstrual cycle begins with the first day of woman’s menstrual period and lasts until the first day of the next monthly period. The average menstrual cycle is right around 28 days but may range anywhere from 21 to 35 days depending on the individual. The average length of the bleeding portion of the cycle can
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TABLE 17-1 Patient Screening and Instructions for Breast Screenings and the Female Reproductive System
BREAST SCREENINGS ASK THE PATIENT: “ARE YOU EXPERIENCING ANY. . .”
Pain, tenderness, swelling, drainage, odor, change in the size, fever, or any dimpling? Is there a familial history of breast disease?
DISROBING INSTRUCTIONS
Remove all clothing from the waist up.
VITAL SIGNS
Blood pressure, temperature
EQUIPMENT
None
POSSIBLE PROCEDURES
In office: None Out of office: Breast ultrasound mammogram, or breast biopsy
FEMALE REPRODUCTIVE SYSTEM ASK THE PATIENT: “ARE YOU EXPERIENCING ANY. . .”
Vaginal pain, discharge, or unusual odor, pain during intercourse, any urinary symptoms, abdominal or lower back pain, fever?
DISROBING INSTRUCTIONS
If the patient exhibits vaginal symptoms, disrobe from the waist down.
VITAL SIGNS
Blood pressure, temperature
EQUIPMENT
Pelvic tray with cultures, if applicable
POSSIBLE PROCEDURES
Pelvic exam, STD cultures, urinalysis (if the patient complains of urinary symptoms)
last anywhere from three to eight days. Terms related to menstrual flow include the following: ❖ Amenorrhea: Absence of menstrual flow ❖ Dysmenorrhea: Difficult or painful menstruation ❖ Menorrhagia: Excessive menstrual flow, number of days of flow, or both ❖ Metrorrhagia: Periods of bleeding between the regular monthly flow ❖ Menorrhalgia: Synonymous with dysmenrrohea; pelvic pain during menstruation; may be indicative of endometriosis The menstrual cycle is controlled by hormonal activity within the body. As a woman ages, hormone activity diminishes, stimulating both physiological and psychological changes within the woman. Figure 17-1 illustrates the hormonal and physical changes that occur throughout the menstrual cycle.
Menopause Menopause, defined earlier as cessation of menses, occurs around the age of 52, but can occur anytime after the age of 40. Women can be thrown into “premature” or “induced menopause” as a result of a complete hysterectomy or certain treatments that can damage the ovaries, like radiation or chemotherapy. In some cases, premature menopause can be the result of genetics, autoimmune disorders, or other medical conditions. The ovaries are responsible for storing and releasing eggs and for the production of estrogen and progesterone. When the ovaries stop releasing eggs, hormone production decreases, and menopause occurs. Natural menopause usually occurs in three phases. ❖ Phase 1: Perimenopause begins when estrogen production by the ovaries gradually decreases.
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LEVELS OF GONADOTROPIC HORMONES IN BLOOD
Pituitary gland LH FSH
0
7
14
21
Ovulation
Corpus luteum
28 days
Ovarian cycle
Developing follicles Follicular phase
Luteal regression
Luteal phase
HORMONE BLOOD LEVELS
Estrogen Progesterone 0
7
14
21
28 days
Proliferative phase
Ovulation
Secretory phase
Menstrual phase
7
14
21
28 days
ENDOMETRIAL CHANGES DURING MENSTRUAL CYCLE
Menstrual phase
FIGURE 17-1 A graphic example of the menstrual cycle
0
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This stage normally lasts from one to two years, at which time estrogen production is greatly decreased. Many women will experience the symptoms of menopause during this phase. ❖ Phase 2: Menopause is the complete cessation of menstrual flow. The ovaries have now stopped producing almost all estrogen and have stopped releasing eggs. A diagnosis of menopause is determined after a female has not had a period for 12 months. ❖ Phase 3: Postmenopause is the phase that includes all years after menopause. Usually, menopausal symptoms will stop, but other health risks related to loss of estrogen will continue to increase with natural aging.
Symptoms of Menopause The most common complaint of women during menopause is “hot flashes.” The body experiences a sudden warmness that can range from mild to extremely hot, the skin can become red, and heavy perspiration often occurs. Other symptoms include: Headaches Joint and muscle pain Vaginal dryness Bladder control problems Fatigue Mood swings Insomnia Decrease in concentration Depression Irritability
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C R I T I C A L T H I N K I NG CHALLENGE While you are conducting the patient screening on a woman in her 50s, she asks you your opinion of over-the-counter supplements to help with the symptoms of menopause. 1. What should you tell her? 2. Where might you direct this patient to gain more information about menopause?
Most symptoms are nothing more than a nuisance and only a small percentage of women experience symptoms that are uncomfortable enough to hinder their daily activities. When a woman begins to experience symptoms of menopause, the provider usually orders blood work (FSH level) and a Pap smear to look for vaginal atrophy and thinning. The FSH level rises as the ovaries shut down. The FSH level assists the provider in determining the stage of menopause that the women is in.
Long-Term Health Issues Linked to Menopause The following health problems can be directly linked to the decrease in estrogen that occurs with the onset of menopause. These health issues include: ❖ Poor bowel and bladder function ❖ Heart disease
FIEL D S M A R TS Many women think in terms of their ovaries shutting down when they are going through menopause and expect to see a plunge in all related hormone levels. The reverse is actually true in relation to follicle stimulating hormone (FSH). When estrogen levels dip in the bloodstream, FSH is released from the pituitary to stimulate the development of the egg within the graafian follicle, which secretes estrogen. Once the estrogen levels are elevated, FSH levels will decline until the next dip in estrogen. Due to a lack of egg maturation in menopausal women, estrogen and progesterone levels start to rapidly
decline. The prolonged decreases in the levels of estrogen cause the hypothalamus to send out a releasing factor known as GnRH, which stimulates the pituitary gland to continue to secrete FSH. This process is part of the body’s natural negative feedback response. Therefore, a woman will see slight elevations in FSH during early perimenopause when estrogen levels are just starting to dip, and will see moderate elevations closer to actual menopause and thereafter. These elevations in FSH will continue throughout the woman’s life span.
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❖ Poor brain function with an increased risk of developing Alzheimer’s disease ❖ Osteoporosis (brittle bone disease) ❖ Increased wrinkling of the skin due to poor elasticity ❖ Gingivitis and gum recession ❖ Loss of muscle tone and power ❖ Vision problems, such as cataracts or macular degeneration Several treatment options exist to combat the health problems associated with menopause. The provider and patient should work together to determine the best course of treatment.
Hormone Replacement Therapy Hormone replacement therapy (HRT) used to be common among perimenopausal and postmenopausal women. Women were placed on hormones to help alleviate hot flashes and sleep problems and to help protect them from diseases such as colon cancer, osteoporosis, and heart disease. The latest studies now conclude that HRT may be linked to breast cancer, blood clots, dementia (in a small number of women), and cardiovascular disease. The FDA has changed their guidelines and recommendations for the use of this type of treatment and now recommends that HRT only be used: ❖ To treat or prevent osteoporosis in those women at high risk of developing the disorder. The risks of taking HRT must be weighed against the possible side effects. ❖ Short-term use to relieve perimenopausal symptoms. Again, women must decide if the benefits of using HRT outweigh the risks.
THE GYNECOLOGICAL EXAM The gynecological (GYN) exam consists of a breast exam, abdominal and pelvic exam, and a Pap test. The Pap test, which derived its name from the developer of the test (Dr. George Papanicolaou), is performed to detect early signs of cervical cancer. The GYN exam may also include a wet mount, hanging drop, or KOH wet prep if the patient is complaining of vaginal symptoms (Chapter 29 discusses these three tests in detail). It is recommended that women have an annual GYN exam when they become sexually active or by the time they reach age 20. This exam may be included as part of a complete physical exam or may be performed separately. The GYN exam is not only useful for early detection of cervical cancer, but also breast cancer and other potential health risks related to the female reproductive system. While the order in which steps are performed may differ, the following is a listing of the steps that take place during a GYN exam: 1. Complete and thorough breast exam 2. External pelvic and vaginal exam 3. Collection of tissue for Pap smear and possible cultures when indicated 4. Bimanual pelvic/abdominal exam 5. Rectal–vaginal exam All of these exams are explained in greater detail later in this chapter. The provider may conduct a pelvic exam without performing a Pap test. This is common when the patient comes in complaining of gynecological symptoms.
General Medical Assisting Duties The medical assistant is usually responsible for setting up the room and patient prior to the pelvic exam. The
PAT I E N T T U T O R Patients should be made aware of alternative treatment methods to HRT. There are many herbal remedies on the market as well as transdermal creams and patches that claim to relieve menopausal symptoms. Some medical providers specialize in homeopathic medicine and design specially formulated creams and herbal supplements for individuals looking for alternatives to HRT. There are even compounding pharmacies that specialize in designing these unique for-
mulas. Just because a medication is termed as “natural” or “homeopathic” doesn’t mean that it is without risks. Some natural remedies may also contain trace amounts of estrogen and may pose slight risks for the patients that use them. Whatever the case, patients should be educated about the benefits and risks of all treatments so that they can make informed decisions that are right for their bodies.
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F IEL D S M A R T S It is highly recommended that male providers have a female assistant present whenever performing breast or genital exams. This will help to alleviate false accusations and reduce lawsuits that are unjust.
g
h
b a f c d e
medical assistant usually begins by setting up the Pap tray and related supplies and placing all other necessary equipment in a convenient location. Table 17-2 lists the equipment and supplies that are necessary to complete a GYN exam and Figure 17-2 illustrates the tray set up with the equipment used during the exam. The pelvic tray should be placed at the appropriate height for the provider. If the patient is a new patient, a complete GYN and medical history should be obtained prior to beginning the exam. If the patient is an established patient, the history should be reviewed and amended as necessary. The patient can complete the history herself or the medical assistant may obtain the information by
FIGURE 17-2 A tray set up for a pelvic exam and Pap test when using a liquid prep solution (Refer to Table 17-2 for a description of each item.)
interview. Pertinent information to be included in a complete GYN history includes: ❖ Age at onset of menstrual cycle ❖ Gravida (how many pregnancies?), para (how many live births?), and abortions (specify how many and whether they were spontaneous or elective) ❖ Date of last menstrual period (LMP) ❖ Regularity and duration of cycles
TABLE 17-2 Pap Tray Setup (When Using a Liquid Prep) Refer to Figure 17-2 for a photo of the tray items. ON THE TRAY
OFF TO THE SIDE
Vaginal speculum (may be metal or plastic) (a)
Patient gown and drape
Liquid prep solution (ThinPrep® or SurePath®) (b)
Tissues
Cervical scraper or plastic spatula (c)
Gooseneck lamp
Endocervical brush or broom (d)
Biohazard container
Plastic cotton-tipped applicators, if needed (e)
Cytology requisition form
Lubricant (f) Appropriate cultures, if needed (not pictured) Gauze squares (g) Two pairs of gloves (one pair for the provider and one pair for the medical assistant) (h) Fecal occult test supplies for women over the age of 40 (not pictured) Note: If the provider is using the direct smear method to collect the cells in place of the liquid prep solution, the medical assistant will prepare two or three slides depending on the provider’s preference.
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Many EMR software programs have templates designed for specialty exams. Templates allow the user to just point to the usual questions asked during a GYN screening, and click on usual responses given to those questions. This cuts down on the amount of documentation that has to be entered and saves time for all parties involved.
I sure wish I didn’t have to answer all of these questions. They are really embarrassing. I am ashamed of my sexual history and don’t want to share the information with anyone—even the physician. I really should be tested for HIV and other STDs, but I just don’t know that I can trust the workers in this clinic to keep my information confidential. My cousin is friends with one of the medical assistants here. If this information gets out it could ruin my marriage.
❖ ❖ ❖ ❖ ❖
Date of last Pap Any history of abnormal Pap or biopsies Contraception method used HRT information Date of last mammogram for women over 40 or who are at high risk ❖ Types and dates of GYN surgeries ❖ Sexual activity and history (up to provider) ❖ Signs or symptoms of GYN disorders including vaginal discharge or painful intercourse The medical assistant should obtain the patient’s weight and perform a set of vital signs either prior to or following the GYN history. Patients around the age of menopause and following menopause should also be measured to see if there is a decline in height due to a loss of bone density.
After obtaining a complete GYN history, the medical assistant will prep the patient by instructing her to empty her bladder and giving her proper disrobing instructions. The patient should be instructed to sit on the exam table until the provider enters the room to begin the exam. Sitting on the table is more comfortable than being placed in the lithotomy position for a prolonged period of time. Another responsibility of the medical assistant will be preparing the liquid prep solution or Pap slides to be sent to the laboratory. A cytology request form must accompany the specimen to the laboratory. After the exam is completed, the medical assistant will clean the exam room and prepare it for the next patient. Procedure 17-1 lists the steps involved in assisting with a GYN exam.
PAT I E N T T U T O R Signs to look for include: ❖ A prominent lump or nodularity ❖ Bloody, brown, or serous discharge from the nipple ❖ Dimpling ❖ Nipple retraction ❖ Skin discoloration The patient should become familiar with her breasts and report any changes to her provider immediately.
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The importance of breast self-examination must be stressed to all women above age 20. Breast cancer does not occur just in older women, but in younger women as well. Patients must be taught to perform BSE every month at approximately the same time of the month, usually 7 to 10 days after the start of the last menstrual period. If the patient is postmenopausal, she should be instructed to choose a date, such as the first or fifteenth of each month, and conduct the self-exam. Breasts should be examined in the shower, in front of a mirror, and while lying down.
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Mammography and Breast Exam Mammography is an x-ray of the breast tissue used as a screening method for the early detection of breast cancer. During a mammogram, each breast is compressed between two plates to flatten the tissue, making visualization easier. A view of each breast is taken from top to bottom and side to side.
FIGURE 17-3 Three methods of BSE should be performed monthly: in the shower, in front of a mirror, and while lying down. Refer to Procedure 17-2 for details.
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The American Cancer Society recommends that all females 20 years of age and older perform monthly breast self-examinations (BSEs) and that females ages 20 to 39 also have a clinical exam of the breast every three years. The guidelines also recommend that all females age 40 and over should have a yearly mammogram and clinical breast exam. Those females with a strong family history should begin mammography at a younger age. Although mammography is not “foolproof” in that it does not detect 10% of breast cancers, it is still the most effective means of early detection. Mammography can detect a tumor up to two years before either the patient or the provider can feel it. The provider usually begins the clinical breast exam with the patient in a sitting position. A visual inspection of each breast is performed noting any redness, puckering, or dimpling of the skin. The patient is then instructed to lie back and place both hands behind or over her head. The provider then palpates both breasts and axilla for any lump or thickening. The patient will also be asked if she is performing BSEs and if not, the provider may ask the medical assistant to instruct the patient on proper technique. Written instructions should be provided, in case the patient has questions about the procedure once she leaves the office. Figure 17-3 illustrates the proper technique for performing three methods of BSE, Figure 17-4 shows a breast self-examination model, and Procedure 17-2 lists the proper steps for instructing a patient on the correct way to perform BSE.
FIGURE 17-4 The breast self-examination model contains lumps and thickenings for training the patient to locate and feel abnormalities. Instructions
Prosthesis Powder
Finger pads
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Speculums are available in different sizes and are either disposable plastic or reusable metal. A metal speculum should be warmed before insertion for patient comfort. Holding the metal speculum under warm running water for several seconds should accomplish this and will also provide some lubrication.
It is important to remember that a Pap test detects cervical cancer and some other benign conditions of the cervix and vagina. Women who have had partial hysterectomies are still at risk of cervical cancer and should continue to have Pap smears. The Pap test does not, however, provide any information about the status of the endometrium inside the uterus. An endometrial biopsy must be performed in order to evaluate the lining of the uterus for abnormalities or endometrial cancer.
The Pelvic Exam The provider will conduct a pelvic exam that consists of several components. First, a visual inspection of the external genitalia is conducted. Next, the cervix and vagina are visually examined. To do this, the provider inserts a speculum into the vagina to hold the vaginal walls apart making visualization easier. Figure 17-5 illustrates proper speculum insertion.
FIGURE 17-6 The cervix is scraped with a spatula to obtain cells for a Pap test. Speculum
Vaginal walls
Pap Test If a Pap test is to be performed, cells from the cervix are obtained for cytologic evaluation. The Pap test, mentioned earlier, can detect cervical cancer in the early stages and can also detect any atypical cells or inflammation that may be present. Cells are collected from the cervix and endocervical canal by scraping the area (Figure 17-6) with a cervical spatula and brush or just a cervical broom (Figure 17-7).
FIGURE 17-5 A vaginal speculum is inserted to observe the vagina and cervix and to obtain a sample for the Pap test. Vagina
Cervix
FIGURE 17-7 A spatula and brush, or just a broom, may be used to collect cells when obtaining a specimen for the liquid prep method.
Bladder Fallopian tube
Speculum
Ovary
Liquid prep solution
Uterus
Cervical spatula
Vertebra
Cervical brush Cytology brush
Cervix of uterus
Rectum
Cervical broom
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Once the specimen is collected, the medical assistant will prepare the slides to be sent to the laboratory for evaluation. The slides must be properly labeled and must be accompanied by a cytology lab requisition (Figure 17-8) containing all pertinent information. Slides must be labeled with the proper patient identification, and the source of the specimen labeled as (V) for vaginal, (C) for cervical, or (E) for endocervical. One of two methods may be used to collect and preserve cells for a Pap test: 1. Conventional/direct method: Cells are collected and spread onto a slide that is placed into a jar with a liquid fixative, or the slide may be sprayed with a fixative and placed in a protective slide holder to be sent to the lab. (The fixative should be applied immediately after the cells are placed on the slide. Allowing the cells to dry on the slide can cause inaccurate readings.) 2. Liquid prep method: A specimen is collected and the collection device is agitated in a vial of liquid preservative to remove the cells. The vial is sent to the laboratory where slides are prepared, fixed, and
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C R I T I C A L T H I N K I NG CHALLENGE A patient who has had a hysterectomy calls and is very upset because a neighbor told her that she should have been having annual Pap/pelvic exams following her hysterectomy three years ago. The patient states that she was never informed about this and wants to know if the neighbor is correct. 1. Is the neighbor correct? Should the patient still have Pap/pelvic exams even though she had a hysterectomy? Explain the reason for your answer. 2. How will you address the patient regarding the fact that she was never told she was supposed to continue to have her annual Pap/pelvic exam?
FIGURE 17-8 A lab request form for a cytology examination
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stained. The liquid prep method has certain advantages over the direct method (see Table 17-3). ViraPap ViraPap® is another testing method that can be performed on the same specimen as the ThinPrep. This test detects the presence of human papillomavirus (HPV), which has been found to increase a woman’s risk of developing cervical cancer. Interpreting Pap Test Results The National Cancer Institute (NCI) developed a system for grading Pap tests that provides detailed information about the results. This system of reporting Pap results is known as the Bethesda system (TBS) and is divided into three parts (Table 17-4). Any patient with an abnormal Pap will receive further testing.
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FI E L D S M A R T S A Pap smear can now be performed on a patient that is bleeding using the liquid prep method. The liquid prep solution and cells from the patient are spun in a centrifuge that separates the red cells from the rest of the specimen. This works out well for the patient that has irregular periods and never knows when to schedule her Pap smear.
viders may also obtain a small fecal sample for occult blood testing.
Bimanual Pelvic Exam Following the collection of the sample for the Pap test, the provider will remove the speculum to perform the bimanual exam. The provider lubricates the index and middle fingers of a gloved hand and gently inserts them into the vagina and presses on the abdomen with the other hand, to palpate the internal pelvic organs (uterus and ovaries). The organs are palpated for abnormalities such as lumps or areas of tenderness. If any abnormalities are detected, further testing is indicated.
Rectal Exam The rectal exam may or may not be performed. The provider will insert one finger in the rectum or one finger in the rectum and vagina simultaneously. Tone and position of the pelvic organs are assessed along with detecting the presence of any rectal abnormalities, such as hemorrhoids, fistulas, and fissures. Some pro-
GYNECOLOGICAL DIAGNOSTIC TESTS AND PROCEDURES When potential problems are discovered by the patient or their provider, further diagnostic testing may be necessary to arrive at a diagnosis and to determine the best course of treatment. Table 17-5 lists some of the common diagnostic tests and procedures.
SEXUALLY TRANSMITTED DISEASES Sexually transmitted diseases (STDs), also referred to as sexually transmitted infections (STIs), continue to be a problem despite all of the education available on the topic. There are a variety of diseases that are considered STDs; they affect all age groups, including
TABLE 17-3 Direct versus ThinPrep Pap Method DIRECT METHOD
LIQUID PREP METHOD
Only a small portion of cells is smeared on the slide; 80% of the cells remain on the collection device.
Almost 100% of the specimen is rinsed from the collection device, providing the laboratory with a complete specimen for evaluation.
Cells can be unevenly distributed, and the slide may be contaminated with debris such as mucus and blood cells, making it difficult to evaluate.
The preparation process eliminates debris and evenly distributes a thin layer of cells on the slide.
Detects only cervical cancer
The same specimen may be used to detect chlamydia, human papillomavirus (HPV), and gonorrhea.
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TABLE 17-4 Bethesda System for Reporting Pap Results
Part 1
Suitability of sample
This section rates the sample as satisfactory or unsatisfactory for evaluation. If unsatisfactory, the laboratory will provide the provider with a reason for rejection, such as “too few cells” or “blood present on specimen.”
Part 2
General categorization
This section indicates if the cells are normal or abnormal and describes them as: Negative for intraepithelial lesion or malignancy: This means that the cells were normal and no cancerous or precancerous cells were found. Within this category, noncancerous or benign changes—such as inflammation or vaginal infections like chlamydia, trichimonas, candidiasis, and herpes—are also reported. Epithelial cell abnormality: This indicates that abnormal cell changes were present with the abnormality described in detail. Other: This can indicate that increased risk is indicated for something other than cervical cancer, such as the presence of endometrial cells in postmenopausal women, which could signal a problem with the endometrium of the uterus.
Part 3
Descriptive diagnosis
When an abnormality is found cell changes may be described as the following: 1. Negative for intraepithelial lesion or malignancy, but abnormality may be caused by: Infection by organisms such as bacteria, trichimonas, actinomyces, yeast infection (candidiasis), chlamydia Reactive changes due to use of an IUD (intrauterine device), radiation exposure, inflammation from normal cell repair Glandular cells present post-hysterectomy Atrophic changes resulting from decreased levels of estrogen during perimenopause and postmenopause 2. Epithelial cell abnormalities: Squamous cell: Atypical squamous cells (ASC): used for minor cell changes of unknown origin. This classification is divided into two types: a. Atypical squamous cells of undetermined significance (ASC-US) b. Atypical squamous cells that cannot rule out high grade intraepithelial lesion (HSIL or ASC-H) Low-grade squamous intraepithelial lesions (LSIL), including cells that display definite minor changes, but are unlikely to become cancerous. Includes: HPV, mild dysplasia (abnormal development); cervical intraepithelial neoplasia (abnormal formation of tissue) (CIN-1) High grade squamous intraepithelial lesions (HSIL): cells that display changes that have a higher likelihood of becoming cancerous; cervical intraepithelial neoplasia (moderate dysplasia) (CIN-2); cervical intraepithelial neoplasia (severe dysplasia) (CIN-3); carcinoma in situ (CIS); changes indicative of invasive cancer Squamous cell invasive cancer 3. Glandular cell abnormalities: Atypical glandular cells (ACG): endocervical cells (from the cervical canal); endometrial cells (in the cervix; abnormal in postmenopausal women not on HRT) Atypical glandular cells displaying neoplastic changes: endocervical cells, glandular cells Endocervical adenocarcinoma in situ (AIS) Adenocarcinoma: endocervical, endometrial, extrauterine Other unspecified
Source: National Institute of Health, http://www.nih.gov.
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To provide the laboratory with the best possible specimen for cytologic evaluation, the patient must be properly prepared. The patient must adhere to the following preparation guidelines. ❖ Schedule the Pap test 10 to 20 days after the last menstrual cycle. Blood cells present in the specimen will make the specimen difficult to read when using the slide method. ❖ Do not douche prior to the test. Douching washes away many of the cells and
the specimen produces fewer cells for evaluation. ❖ Do not insert vaginal medications or spermicide for two days prior to the test. Both change the pH of the vagina, making the specimen invalid. ❖ Abstain from sexual intercourse for two days prior to the test. Intercourse can produce inflammation that can make the cells look abnormal.
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TABLE 17-5 GYN Diagnostic Tests and Procedures PROCEDURE NAME
DESCRIPTION
RATIONALE
Amplified DNA probe
Rapid test kit for the detection of chlamydia and gonorrhea
Screening test for men and women Performed on all pregnant females
Open surgical removal of the lump or a needle biopsy in which a small incision is made and a vacuum-needle is inserted and the specimen is obtained Several tissue samples are taken using a colposcope and biopsy forceps Removal of endometrial tissue for microscopic evaluation
Performed after a clinical exam, mammography, or when an ultrasound reveals a suspicious mass of any kind
Colposcopy
Visualization of the vaginal and cervical tissue with a colposcope
Abnormal Pap results
Cryosurgery
Cervix is frozen using liquid nitrogen
Cervicitis Cervical erosion
Dilation and curettage (D & C)
Cervix is dilated and some of the endometrial lining is scraped off
Evaluation of tissue due to excessive bleeding Removal of remaining tissue after a miscarriage
Loop electrosurgical excision procedure (LEEP)
Removal of abnormal tissue from the cervix using thin wire loop electrodes
Cervical dysplasia
Ultrasonography
Harmless sound waves are bounced off internal structures, which produce images of the uterus, ovaries, and the fetus
To detect abnormalities of the ovaries and uterus Tubal/ectopic pregnancies Fibroids Cysts
Biopsies: Breast
Cervical punch Endometrial
Usually performed after abnormal Pap results to detect the presence of malignant cells Abnormal bleeding Infertility
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seniors. The fastest rise in STD percentages over the last few years have been in the senior population. There are several opinions as to why the number of senior cases is on the rise, including accessibility to drugs like Viagra for men who would otherwise be unable to perform sexually, and the opportunity for seniors to meet other seniors through senior communities and over the Internet. Many seniors are unaware that they need to use protection because there is no longer a risk of pregnancy, and many assume that they are in monogamous relationships so there is no risk of contracting an STD. Of course all age groups are at risk for contracting STDs. The medical assistant is usually responsible for delivering patient education in this area. A great Web site to get brochures and fact sheets regarding this topic is http://www.cdc.gov/std. Some brief information regarding STDs can be found in Table 17-6 and the Patient Tutor tool box on this page.
OBSTETRICS Obstetrics (OB) is the medical specialty that provides care and treatment to the pregnant female. Obstetrical care is provided during pregnancy (prenatal), labor and delivery, and the postpartum period, also known as the puerperium period. A full term pregnancy is considered to be from 37 to 40 weeks gestation and is divided into three trimesters at approximately three months each. Adhering to a regular schedule of prenatal visits is important in order to follow the progression of the pregnancy and to monitor the health of both the mother and fetus. Early detection of potential problems can prevent serious complications for the mother
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PATIENT TUTOR According to the CDC, genital HPV is the most common sexually transmitted infection in the United States; an estimated 6.2 million persons are newly infected every year. Although the majority of infections cause no clinical symptoms and are self-limited, persistent infection with oncogenic (cancer-producing) types can cause cervical cancer in women. A rather new vaccine on the market (referred to as the HPV vaccine) is recommended for all girls between the ages of 9 and 26. The vaccine series is a combination of three separate shots. The series has had great success and the number of woman with HPV infection is expected to plummet over the next several years. Patients should be warned, however, that the vaccine does not protect them from all forms of HPV.
and baby. Table 17-7 lists the recommended schedule for prenatal and postpartum visits.
PRENATAL CARE Due to a wide variety of in-home pregnancy tests, a woman can now confirm a pregnancy almost immediately after conception. Prenatal care can begin sooner, due to early confirmation, and new mothers
TABLE 17-6 Sexually Transmitted Diseases (STDs) STD
SYMPTOMS
TREATMENT
Chlamydia (bacterial infection)
Vaginal discharge Painful urination
Tetracycline or erythromycin
Gonorrhea (bacterial infection)
Women are usually asymptomatic, but may develop inflammation with a greenish discharge
Tetracycline or penicillin
Genital herpes (viral infection)
Fluid-filled vesicles on the genitalia
No cure; treatment with antiviral medication can help prevent outbreaks
Syphilis (bacterial infection)
Vary according to stage of disease: during the first Penicillin stage, a lesion called a chancre appears; second stage, a rash on hands and feet appears; third stage, no symptoms until nerve or organ damage is present
Note: Information about HPV can be found in the Patient Tutor tool box on this page and HIV information can be found in Chapter 10.
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TABLE 17-7 Schedule of Exams Initial exam: approximately six weeks gestation
amount of flow. Any past gynecological problems can also be reviewed. It should also be noted if the patient became pregnant while on birth control.
Every four weeks until 30 weeks gestation
Estimated Date of Confinement
Every two weeks from 30 to 36 weeks gestation
Once the pregnancy is confirmed, the mother is anxious to determine the expected delivery date (EDD) or estimated date of confinement (EDC). Although there are no perfect methods for determining an exact date of delivery, a formula known as Nagele’s Rule is considered to be fairly accurate:
Every week from 36 to 40 weeks gestation Six weeks after delivery
Nagele’s Rule: First day of LMP + 7 days – 3 months + 1 year can begin preparing much earlier than ever before for their baby’s arrival. It is vital for expectant mothers to adhere to the schedule of prenatal visits, as recommended by the provider, and that their initial visit be scheduled by their sixth week of pregnancy.
Example: January 11, 2009 + 7 days = January 18, 2009 January 18, 2009 – 3 months = October 18, 2008 October 18, 2008 + 1 year = October 18, 2009 (EDD)
The Initial or First Prenatal Exam
A pregnancy wheel or gestational calculator, such as the one pictured in Figure 17-9, may also be used.
The first prenatal exam is usually scheduled after a woman obtains a positive pregnancy test result at home or after she has missed a second menstrual cycle. Confirmation of the pregnancy and a thorough history and physical will be completed during the first office visit. Baselines will also be established to be used as future reference points. The provider will be looking for any potential disorders that could have an adverse affect on the mother or child. Early detection of potential problems can alert the provider to possible complications that may occur during the pregnancy and birth process. Sufficient time should be allotted to complete the initial prenatal exam. A larger block of time will be needed to obtain the history, complete the physical exam, and provide the patient with important information regarding her pregnancy. Parts of the initial exam include: ❖ Complete medical history, including menstrual and prenatal history: A thorough database can assist the provider in identifying high-risk patients. Any problems related to previous pregnancies and deliveries should also be noted including miscarriages and abortions. ❖ Physical exam, which includes a breast, abdominal, pelvic and vaginal exam, along with pelvic measurements ❖ Patient education ❖ Laboratory tests The patient’s menstrual history is also reviewed to determine onset, regularity, length of cycle, and
Patient Preparation After completing the prenatal record, the medical assistant will obtain the patient’s height, weight, and vitals and then ask the patient to empty her bladder. While the patient is voiding, the medical assistant can set up the exam room with any equipment needed by the provider, and place a gown and drape on the exam
FIGURE 17-9 An example of a gestational wheel for calculating the estimated delivery date of the fetus
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C U LT U R A L AWA R E N E S S A woman’s ethnic background can dictate how prenatal care is delivered. Modesty is paramount in some cultures and women may not be permitted to be examined by a male provider. Some Hispanic women are cautioned not to observe an eclipse of the moon because it is believed it may cause the baby to have congenital defects. They sometimes wear a braided cord around their waists to ensure an uncomplicated birth and to decrease nausea. Some cultures believe
table for the patient. The medical assistant should give thorough disrobing instructions and should instruct the patient to sit on the exam table until the provider enters the room to begin the exam.
that a pregnant female should be very inactive in order to protect the health of the baby, while others believe that wearing beads, amulets, or a talisman will drive away evil spirits. Dietary restrictions also apply in some cultures during pregnancy. Never make light of a custom or make the patient feel inferior. Share any information that you gain during the interview with the provider so that the provider can properly counsel the patient.
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Parts of the Initial Prenatal Exam Components that are generally included in the first prenatal exam are listed in Table 17-8 along with the rationale for each component.
TABLE 17-8 Segments of the First Prenatal Exam SEGMENT
CONDUCTED BY
RATIONALE
Complete medical and prenatal history
Provider or medical assistant
Reference base
Vitals: TPR and BP
Medical assistant
Reference point for return prenatal visits
Weight
Medical assistant
Beginning weight must be measured for a baseline
General physical exam
Provider
Determines the woman’s overall general health
Breast exam
Provider
Examine the breasts to determine if there are any potential problems and to check for breast changes that are normally present during pregnancy
Abdominal exam with fundal height measurement
Provider
Detection of any abnormalities, such as lumps or swelling that are not part of normal fetal development
Pelvic exam including cultures for chlamydia and gonorrhea
Provider
Detection of any abnormalities that could complicate the pregnancy or delivery Screen for STDs Estimation of gestational age
Rectal–vaginal exam
Provider
Detection of any abnormalities in the rectum and to estimate vaginal strength
Pelvic measurement
Provider
Determination of the size and shape of the pelvis for the purpose of delivery
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Initial Prenatal Lab Tests
Return Prenatal Visits
Certain laboratory tests are performed as part of the initial prenatal exam. Conditions may exist that could pose a danger to the mother and the fetus. Cytology, blood, and urine specimens are collected. Table 17-9 lists the traditional prenatal lab tests. Following completion of the exam, the patient should be encouraged to ask any questions before leaving the office. They should also be instructed to report any signs or symptoms of possible problems, immediately. Table 17-10 lists signs and symptoms that could be cause for concern.
Once the initial visit is completed and the prenatal database has been established, the patient is seen at regular intervals until the baby is delivered. The schedule for return visits may differ somewhat from one provider to the next, but will usually be as stated in Table 17-8. During subsequent OB/GYN visits, the medical assistant will be responsible for weighing the patient and obtaining a blood pressure reading. A urine sample should be collected and tested for glucose and protein (Figure 17-10). A positive glucose reading may
TABLE 17-9 Traditional Prenatal Lab Tests TEST
RATIONALE
Complete urinalysis (if bacteria is present, cultures should be performed)
To screen for a UTI, hypertension, diabetes mellitus, renal disease
Pap
To screen for any cervical abnormalities or herpes simplex II
Smear from cervix, rectum, or vagina
To screen for chlamydia, gonorrhea, and HPV
Trichomonas/Candida screen (if unusual vaginal discharge is present)
To rule out trichomoniasis and candidiasis
Group B strep screen
To detect the presence of group B strep in the vagina or rectum. If present, it could produce life-threatening infections in the infant.
EKG
To evaluate the mother’s cardiac health
CBC
To detect anemia or a possible asymptomatic infection
ABO and Rh Blood Types
To determine ABO and Rh compatability of mother and fetus
Rubella titer
To detect levels of antibodies to the rubella virus. If the mother is not immune, contracting the disease during pregnancy could cause serious birth defects. Mothers with no immunity are given an immunization within six weeks of delivery.
Blood glucose
To screen for gestational diabetes
Renal function tests
To determine proper renal function and to detect the presence of renal disease
VDRL and RPR
To detect syphilis
HIV
To detect the presence of the HIV virus or antibodies against it
Hepatitis B and C
To screen for Hepatitis B and C in the mother
TB test
To screen the mother for tuberculosis
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PAT I E N T T U T O R Patients should be educated regarding facts related to alcohol, tobacco, and recreational drug use during pregnancy. Patients must be warned of the complications that can occur when these products are used. Smoking can cause low birth weight and premature births. Using alcohol and other drugs can cause birth
defects like fetal alcohol syndrome (FAS). Children with FAS often have distinctive facial features including a small head and eyes, a wide flat nasal bridge, and a small jaw. They may also experience abnormalities in growth and central nervous system (CNS) malfunctions, along with mental retardation.
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TABLE 17-10 Signs and Symptoms of Possible Pregnancy-Related Problems POTENTIAL PROBLEM
SIGN/SYMPTOM
Preeclampsia/toxemia
Edema, headache, rapid weight gain, increased blood pressure, visual disturbances
Hyperemesis gravidum (could result in dehydration)
Severe nausea and vomiting
Possibility of a miscarriage Placenta previa Placenta abruptio
Abdominal pain, bleeding, discharge
Possible infection
Fever, chills, decreased urine output, frequent or painful urination, vaginal discharge
Preterm labor
Cramping, pelvic pressure, low-back pain, regular contractions
Note: Descriptions of the medical terms used in this table can be found in Table 17-12.
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PATIENT TUTOR
A patient in her fourth month of pregnancy phones the office to say she is experiencing fever, chills, frequent urination, and vaginal discharge. 1. How soon should the patient be seen? 2. What should you instruct the patient to bring with her to the office?
Preeclampsia (also known as toxemia) is a dangerous complication that can develop during pregnancy. The patient often presents with protein in the urine, along with an elevation in blood pressure, and severe swelling in the lower limbs. Some studies have shown a direct relationship between a lack of protein and other nutrients in the diet and the development of metabolic toxemia. Therefore, proper nutrition may play an important role in preventing toxemia. Patients should be encouraged to take in a minimum of 75 to 100 grams of protein a day along with other essential vitamins and minerals. Water should be increased to help keep the kidneys functioning.
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FI E L D S M A R T S Providers often request that pregnant patients be placed on their left side when their blood pressure reading is elevated. This positional change helps to reduce blood pressure. The blood pressure is monitored throughout the visit to see if there are any changes.
indicate gestational diabetes, while a positive protein reading could be an indication of preeclampsia. The medical assistant will then obtain information from the patient about any problems since their last visit. Questions posed to the patient should include:
(a)
❖ Any vaginal bleeding? If so, list amount, any clots or tissue passed, or any cramping. ❖ Any fluid leakage? ❖ Any unusual vaginal discharge? ❖ Any headaches, dizziness, or vision problems? ❖ Any unusual swelling? ❖ Any nausea or vomiting?
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(b)
FIGURE 17-10 (a) The patient labels a sample cup in preparation for collecting a urine sample. (b) A medical assistant usually tests the urine for glucose and protein; however, here a physician performs the test.
A patient calls the office and states that her extremities and face are very swollen. The patient feels fine but just wonders what might be causing the swelling. You offer the patient an appointment but she refuses, stating that her schedule is too busy. She asks if there is any kind of a “water” pill she can take to help remove the excess fluids from her body. She goes on to state that her mother takes a diuretic and wonders if she may be able to take one of her pills. 1. What could be the cause of the patient’s swelling? 2. What would you say to a patient that wants to take another person’s medication? 3. Why should the patient be seen as soon as possible? 4. What might you expect to see in the patient’s urine upon testing?
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The stage of pregnancy will determine which exam techniques and tests are conducted during standard OB visits. Once the medical assistant has finished recording pertinent screening information, the provider will perform the following tasks.
Fundal Height As the uterus increases in size, fundal measurements are taken by using a tape measure and measuring from the top of the pubic bone to the top of the uterus. This is recorded in centimeters and is usually within 1 to 3 cm of the gestational age of the fetus in weeks, so a fundal height of 22 cm would be normal for a patient that is 24 weeks pregnant. Fundal height measurements help the provider to determine duration of pregnancy and may also help to detect abnormalities that should be further evaluated. The first measurement, obtained at the initial prenatal visit, serves as a baseline for comparison of future measurements. Figure 17-11 shows the physician obtaining a fundal height measurement.
(a)
Monitoring Fetal Heart Tones Somewhere between 10 and 12 weeks gestation, the fetal heart tones can be heard with a fetal pulse detector (Figure 17-12) through the mother’s abdominal wall. Normal fetal heart rate is 120 to 160 BPM. A slow or rapid rate could be an indication of fetal distress and requires further investigation.
(b)
FIGURE 17-12 (a) Fetal heart tones are measured. (b) An example of a handheld Doppler for detecting fetal heart tones
Vaginal/Internal Exam A vaginal or internal exam may be performed at any time during the pregnancy, but is typically performed
two to three weeks prior to delivery. The obstetrician will assess cervical dilation and effacement (thinning of the cervix). To facilitate fetal delivery, the cervix must be completely effaced and dilated to 10 cm.
FIGURE 17-11 The fundal height measurement is obtained.
PRENATAL DIAGNOSTIC TESTS AND PROCEDURES Additional tests or procedures may be performed at specific intervals during the prenatal period to detect possible genetic abnormalities. Table 17-11 lists specialized prenatal diagnostic tests.
Ultrasound Since ultrasound uses sound waves, not x-rays, it is safe to administer during pregnancy and will pose no threat to either the mother or fetus. An ultrasound exam allows the provider to obtain a multitude of information about the pregnancy and the fetus and can detect problems such as ectopic (tubal) pregnancy.
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TABLE 17-11 Prenatal Diagnostic Tests TEST
DESCRIPTION
WHEN PERFORMED
POSSIBLE INDICATIONS
Alpha-fetoprotein (AFP)
Test is performed to detect neural tube defects
15 to 18 weeks gestation Patient permission required
Decreased levels indicate an increased risk of Down syndrome. Increased levels may indicate an increased risk of spina bifida or anencephaly.
Glucose challenge
Screening test for gestational diabetes
24 to 28 weeks gestation
A positive result will require a longer glucose tolerance test to determine if gestational diabetes is present.
Amniocentesis
Amniotic fluid is aspirated and tested for chromosomal abnormalities. Analysis of the fluid can also determine the gender of the baby.
14 to 16 weeks gestation In patients over the age of 35 Family history of genetic disorders
Congenital abnormalities Fetal lung capacity
Fetal heart rate monitoring
Non-stress test: monitors changes in the baby’s heart rate during fetal movement Contraction stress test: monitors changes in the baby’s heart rate when mild uterine contractions are stimulated
Later in pregnancy
Detects placental function Performed on patients with: Gestational diabetes Increased fetal movement or growth Decreased amniotic fluid Hypertension
Chorionic villi sampling (CVS)
Sample of tissue that sur8 to 10 weeks gestation rounds the fetus is suctioned through a catheter for chromosomal analysis
Thalassemia Sickle cell anemia Tay-Sachs
Ultrasound
High frequency sound waves produce an image of the fetus
Detects: Ectopic pregnancies Abnormal bleeding Fetal growth Gender determination Multiple fetuses Placental position
Performed at different intervals throughout pregnancy
The ultrasound can be performed at any time during pregnancy, but is typically performed at: 1. 12 weeks to: • Detect fetal heart beat • Confirm gestational age 2. 18 to 20 weeks to: • Detect multiple fetuses • Examine the brain, spinal cord, internal organs, and extremities
• Check the position of the placenta • Perform a measurement of fetal growth, size, and weight • Detect any congenital abnormalities present 3. 34 to 37 weeks to: • Measure fetal growth, size, and weight • Determine fetal position • Determine position of placenta
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Ultrasounds can be performed abdominally or intravaginally (Figure 17-13). An ultrasound study is also performed during an amniocentesis to guide the needle (to prevent injury to the fetus), to detect any abnormalities present, and to confirm a suspected intrauterine death.
Amniocentesis An amniocentesis is a prenatal procedure performed to detect certain genetic abnormalities, metabolic disorders, and chromosomal disorders such as Down syndrome and other neural tube defects. It is sometimes performed to evaluate the lung maturity of the fetus and can also determine the gender of the fetus. A long thin needle is inserted through the abdominal wall into the amniotic sac (Figure 17-14), and amniotic fluid is withdrawn for analysis. While there is FIGURE 17-13 (a) A technician performs a prenatal abdominal ultrasound. (b) A transducer is used to perform a transvaginal prenatal ultrasound.
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a low risk of complications as a result of amniocentesis, slight risks do exist. Some potential problems that may occur are: ❖ ❖ ❖ ❖
Bleeding Leaking of amniotic fluid Infection Miscarriage
FIGURE 17-14 Amniocentesis is performed to withdraw amniotic fluid for analysis.
Uterine Amniotic cavity wall Placenta
TOOL BOX (a)
FI E L D S M A R T S Because an amniocentesis is not risk-free, it is usually performed only under certain conditions. Amniocentesis is often recommended when: ❖ The mother is 35 or older ❖ The mother has already had a child with a genetic disorder or neural tube defect ❖ The mother’s blood work is abnormal ❖ One parent has a known chromosomal abnormality ❖ One parent is a known carrier of a metabolic disorder
(b)
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PREGNANCY COMPLICATIONS Many complications can arise during pregnancy, labor, and delivery. Table 17-12 lists some of the possible complications that can occur.
LABOR AND DELIVERY Labor or parturition commences when the uterus begins to contract and ends with the delivery of the baby. As delivery nears, decreased levels of progesterone signal the uterus to produce prostaglandin and to begin contracting. Prostaglandin causes the pituitary to release oxytocin, a hormone that produces strong uterine contractions. Occasionally, Braxton-Hicks contractions or false labor can be mistaken for true labor. Braxton-Hicks are intermittent and painless contractions occurring every 10 to 20 minutes. BraxtonHicks do not occur in all pregnancies. If spontaneous rupture of the fetal membrane has not occurred, the provider may rupture the amniotic sac by puncturing it with an instrument. The rupture of the membrane may decrease the mother’s time in labor. Labor occurs in three stages: ❖ Stage I (Dilation): Once labor begins, dilation and effacement of the cervix must occur for the fetus to be delivered. The cervix must dilate or expand to an opening of 10 cm and must be completely effaced or thinned out to facilitate delivery. ❖ Stage II (Explusion): The cervix is completely dilated and effaced and birth occurs. During the birth process, the mother is instructed to “bear down” once the baby has crowned, that is, the top of head is visible. Strong uterine contractions and pushing by the mother move the baby’s head through the vaginal opening. Once the head is out, the baby should turn sideways so the shoulders can pass. When the baby has been delivered, its nose and mouth are suctioned to remove mucus and it begins to cry. Crying inflates and clears the baby’s lungs. The umbilical cord is then clamped and severed. ❖ Stage III (Placental): The placenta, which nourishes and oxygenates the fetus during pregnancy, is expelled after a few more contractions. The uterus should continue to gently contract to close off blood vessels and control postpartum bleeding. Observation of certain signs during labor may indicate complications. Signs include:
❖ Sudden increase or decrease in maternal blood pressure ❖ Heavy vaginal bleeding ❖ Headache or visual disturbances ❖ Increased fetal activity ❖ Meconium (earliest stools of the newborn) in the vaginal discharge If the fetus cannot be delivered through the vagina it may be necessary to perform a cesarean section (C-section). The physician makes a surgical incision through the abdominal wall and into the uterus to remove the fetus and placenta. The incision can be made either transversely (across the abdomen) or vertically (up and down). The rationales for performing C-sections include: ❖ ❖ ❖ ❖ ❖
Small pelvic size Breech position (the fetus is not head first) Ineffective contractions Fetal distress Maternal distress
POSTNATAL OR POSTPARTUM PERIOD Upon delivery of the fetus, the postnatal or postpartum period begins. This period, also referred to as puerperium, lasts from four to six weeks. During the postpartum period, the body and its systems are returning to their prepregnant state. Definite changes occur during this period. The uterus returns to a normal size (involution) and any tissue injuries that occurred during the birth process are healing. A vaginal discharge called lochia, which consists of white blood cells, mucus, bacteria, and tissue, occurs in different stages following delivery: ❖ Lochia rubra: Bright red discharge for the first three days postpartum ❖ Lochia serosa: Pink or brownish discharge occurring on about day four postpartum ❖ Lochia alba: Decreased amount of a yellowishwhite discharge that usually stops at approximately three weeks postpartum, but sometimes lasts for up to six weeks Menstrual flow usually resumes after two months in a non-nursing mother and after three to six months in a nursing mother.
Six Week Postpartum Visit Six weeks after delivery, the patient is seen in the office for her postpartum visit. The provider will examine the
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TABLE 17-12 Complications of Pregnancy COMPLICATION
DESCRIPTION/SYMPTOMS
TREATMENT
Miscarriage/ abortion
Pregnancy ends before the fetus is viable. Six types of miscarriage/abortion: Spontaneous: also known as miscarriage; cause unknown Threatened: uterine bleeding, but no dilation or contractions Induced/abortion: fetus and placenta are evacuated from the mother’s uterus; performed due to a threat to the mother’s health or by maternal request Incomplete: partial expulsion of fetus and placenta Complete: expulsion of all fetal and placental tissue Missed: fetus must be removed after intrauterine death
If bleeding occurs following any of the types of miscarriage or abortion, a D and C is usually performed.
Hyperemsis gravidarum
Excessive vomiting Severe nausea Severe fatigue Severe dehydration Anorexia Possible starvation
IV fluids Mild sedation
Gestational diabetes
Mild form of diabetes that begins in the second or third trimester of pregnancy and resolves when the pregnancy ends.
Diet Medications
Preeclampsia/ toxemia
Condition that causes: Increased blood pressure Edema Proteinuria
Bed rest High protein diet Antihypertensives Mild sedatives Magnesium sulfate
Eclampsia
Same symptoms as preeclampsia along with: Grand mal seizures Coma
Immediate seizure management Induction of labor Cesarean section (C-section)
Placenta previa
Placenta implants low in the uterus and partially or completely blocks the cervical opening. Maternal symptoms: Hemorrhages that recur and increase in severity Pallor Anemia Low blood pressure Rapid weak pulse
Prevention or control of postpartum hemorrhage Prevention of sepsis Treatment for anemia
Placenta abruptio
Placenta abruptly or prematurely detaches from the uterus. Maternal symptoms: Severe pain Tight abdomen Extreme uterine tenderness Absence of fetal heart tones Profuse bleeding Shock
Varies with type and extent of abruption Supportive treatment Surgical intervention if abruption is moderate to severe
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P ATIEN T TU T OR
PATIENT TUTOR
Following delivery, the mother should be instructed to avoid certain activities such as heavy lifting. She should also get lots of rest and engage in a well-balanced diet. The mother should also report any of the following: an increase in the amount of discharge, cessation of discharge within the first two weeks following delivery, discharge with a foul odor, a yellowish-white discharge that changes to red. The mother should be cautioned to report any feelings of depression, as this could be an indication of postpartum depression.
Postpartum depression can begin as long as one to two months after delivery and occurs in about 3% of women. There is a vast difference between the “normal baby blues” that last for a few days and true postpartum depression. Patients suffering from this type of depression need to be closely monitored and may need medication and counseling to help them through this period. Patients should be instructed of what to watch for and report any unusual symptoms or signs. Some of the symptoms include:
patient and evaluate her overall health to determine whether there are any problems that were created by the birth process. The medical assistant will conduct the first part of the postpartum exam by measuring the patient’s weight and obtaining her TPR and BP. The provider will then assess the patient’s general appearance and will also perform a breast and pelvic exam. A Pap is usually not performed at this time due to the presence of abnormal cells given off by the cervix and vagina as part of the normal healing process. Blood work may be performed to detect possible anemia due to blood loss during and following delivery. A rubella immunization is also given if it was determined that the mother did not have antibodies to the rubella virus.
❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖
Uncontrollable crying Despondency Feelings of hopelessness Unable to care for the infant Mood swings Extreme anxiety when it comes to the infant Guilt feelings about not loving the infant Irritability Fatigue Insomnia
The postpartum visit is an excellent time to stress the importance of breast self-examination and yearly checkups by the provider. Different forms of contraception may also be discussed.
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PROCEDURE 17-1 Assist with a GYN Exam and Pap Test Objective: To prepare all necessary equipment and assist the provider with a routine GYN exam including a Pap test.
Equipment/Supplies: ❖ Exam gloves 2–3 pairs ❖ Patient gown and drape ❖ Vaginal speculum ❖ Lubricant ❖ Light source ❖ Tissues ❖ Biohazard specimen bag ❖ Lab requisition Conventional/direct method: ❖ Glass slides
❖ Fixative/specimen jar ❖ Cervical spatula ❖ Endocervical brush ❖ Slide holder ThinPrep method: ❖ ThinPrep vial ❖ Cervical spatula ❖ Endocervical brush ❖ Endocervical broom (when using broom for collection)
PROCEDURAL STEPS
RATIONALE
1. Wash your hands and set up all needed equipment. Warm the speculum.
All equipment should be readily available to prevent any delays during the exam.
2. Label the specimens. Direct method: Label slides with the patient’s name, the date, and source (V) = vaginal, (C) = cervical, or (E) = endocervical. ThinPrep method: Label the specimen container with the patient’s name, date, and ID number (from lab request form).
Labeling specimens before collection reduces slide mix-ups.
3. Identify the patient using at least two identifiers, identify yourself, and instruct the patient to empty her bladder and collect the urine specimen.
An empty bladder makes examination easier and the specimen is often used for a urinalysis.
4. Obtain the patient’s blood pressure and weight and update her medical and GYN history.
Updated information may alert the provider to potential health problems.
5. Explain the procedure to the patient and instruct her to undress completely and to put the gown on so that it open correctly (check provider preference).
Patients are often more comfortable if they know what to expect.
6. Instruct the patient to sit on the exam table until the provider enters the room.
Placing the patient in the lithotomy position for a prolonged period can be uncomfortable.
7. After the provider enters, assist the patient into the supine position and drape for the breast exam. 8. Assist the patient into the lithotomy position and drape for privacy.
Patients often have difficulty getting into the lithotomy position on their own.
9. Hand the warmed vaginal speculum to the provider.
Warming the speculum provides patient comfort. continues
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RATIONALE
10. Adjust the light source for easy visualization. 11. Hand the spatula and brush to the provider when using the direct method, and the broom when using the ThinPrep method. 12. Apply PPE (gloves) and: Direct method: Hold the slides so the provider can apply the collected cells to the slides. Immediately spray the slides with fixative from a distance of 6 inches. Allow the slides to dry for 10 minutes before placing in a holder. ThinPrep method (broom method): Hold the opened vial so the provider can place the broom in the vial (Figure 17-15). Agitate the broom in the solution until all of the specimen has been suspended in the liquid. Dispose of the broom in a biohazard container.
Each method has different collecting supplies.
Prevents the cells from drying on the slide, which distorts their appearance.
FIGURE 17-15 A medical assistant holds the vial for the provider as the provider places the broom into the solution.
13. Squeeze lubricant on the provider’s gloved fingers for the bimanual and rectal exam.
Makes insertion of the fingers easier and more comfortable for the patient.
14. After the provider completes the exam, assist the patient into a sitting position and give her tissues for cleansing the vaginal and rectal area.
Some patients may feel dizzy and unsteady after lying down.
15. Properly dispose of biohazardous wastes and other used supplies and soak the stainless steel speculum in a solution. Sanitize and sterilize the speculum when convenient. 16. Instruct the patient to get dressed. 17. Prepare the specimen and lab requisition for transport (Figure 17-16).
FIGURE 17-16 A medical assistant prepares the specimen for transport to the lab.
18. Remove gloves and wash your hands. 19. Document the procedure in the patient’s chart.
DOCUMENTATION EXAMPLE:
9-18-XX 1030
Pt. here for annual Pap & pelvic. Last Pap, 10-18-XX (normal), G:3 P:3 A:0, LMP 09-1-XX, BC Ortho Evra, GYN surg. None, Sex part. (1), no breast concerns or changes, “performs monthly BSE.” Latania Carter, CMA (AAMA)
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PROCEDURE 17-2 Instruct the Patient in Breast Self-Examination Objective: To instruct a patient in the proper procedure for performing monthly breast self-exam.
Equipment/Supplies: ❖ Pamphlet/shower hanger on BSE ❖ Breast model PROCEDURAL STEPS
RATIONALE
1. Greet the patient, identify yourself, and explain the purpose of BSE.
Explaining the importance of performing monthly BSEs will result in better patient compliance.
2. Give the patient a brochure, such as the ones shown in Figure 17-17, and begin explaining the proper procedure for performing BSE. Explain to the patient that the breasts should be examined in the shower, in front of a mirror, and while lying down (see Figure 17-3).
Written instructions and pictures can help to explain the procedure more clearly. Examining the breasts in three different positions is the most thorough method for detecting abnormalities.
FIGURE 17-17 Samples of BSE pamphlets for home use
3. Instruct the patient to examine the breasts at the same time each month, preferably a few days to a week following menstrual period.
Normal changes of the breast tissue due to hormonal fluctuations during the cycle could be mistaken for an abnormality.
4. While the patient is in the shower, instruct her to cover the right breast with soapy lather and place the right arm over the head. Gently glide the fingers over the entire breast and axilla feeling for any lumps or thickening. Repeat the procedure with the left breast.
Fingers can glide smoothly over the skin while in the shower, making detection of any abnormalities easier.
5. When the patient is finished showering, she should stand before a mirror and and look for: Puckering or dimpling of the skin Redness or a change in skin texture Nipple retraction Any change in size or shape The exam should be repeated with the hands raised over the head and with the hands on the hips, while pressing down.
A tumor may pull the skin inward, creating dimpling or puckering of the skin or retraction of the nipple. Raising the arms over the head changes the position of the breasts and pressing down flexes the chest muscles.
6. Instruct the patient to gently squeeze each nipple and look for any discharge.
A bloody discharge is usually the only reason for concern, but any discharge should be reported to the provider. continues
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RATIONALE
7. Instruct the patient to lie down and place a small pillow under her right shoulder and to raise her right arm over her head.
This position helps to evenly distribute the breast tissue.
8. Instruct the patient to use the pads of the first three fingers and, using firm pressure and a circular motion, examine the entire breast, including the nipple, and the underarm area. Repeat the entire process with the left breast.
Each area of the breast needs to be examined along with the underarm area.
9. Answer any questions and instruct the patient to repeat the instructions and perform an exam on the breast model. Instruct the patient to report any changes immediately.
Early detection is the key.
10. Document the education session in the patient’s chart.
All education sessions must be documented.
DOCUMENTATION EXAMPLE:
10-18-XX 1030
Instructed pt. on proper BSE. Pt. performed BSE on breast model and successfully stated where lumps were located. Pt. given BSE pamphlet and encouraged to call with any additional questions. Joni Leonard, RMA
PROCEDURE 17-3 Assist with the Prenatal Exam Objective: To assist the provider with prenatal exams to monitor the progression of a pregnancy.
Equipment/Supplies: ❖ ❖ ❖ ❖ ❖
Scale Sphygmomanometer Stethoscope Tape measure Patient gown
PROCEDURAL STEPS
❖ ❖ ❖ ❖
Urine specimen cup Urine reagent strips Doppler fetoscope with coupling agent Biohazard waste container
RATIONALE
1. Wash your hands and set up the equipment.
Hands must be washed before and after each patient contact.
2. Identify the patient using two identifiers and instruct the patient to collect a urine specimen. Dip the urine for protein and glucose.
Initial visit: A pregnancy test may be repeated at this visit. Return visits: Urine is tested for protein and glucose, which screens for preeclampsia and gestational diabetes.
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RATIONALE
3. Obtain the patient’s weight and blood pressure. Both measurements are obtained at each prenatal visit (Figure 17-18).
The patient’s weight and blood pressure are monitored throughout the pregnancy to assess maternal nutrition and fetal growth and to alert the provider of the possible development of complications.
4. Initial visit: Have the patient disrobe completely and put on a gown. Assist the provider in conducting a thorough exam including a breast exam and pelvic exam. Return visits: The fundal height is measured and the fetal heart tones are assessed. Assist the provider by supplying a tape measure for the fundal height measurement and a fetal monitor and gel to listen to the fetal heart tones. (After the initial visit, an internal exam will not be performed again until approximately 36 weeks gestation, and thereafter.)
A thorough exam is needed in the initial visit.
5. After completion of the exam, assist the patient into a sitting position and have her remain there for a few minutes.
A sudden drop in blood pressure can occur when rising from a supine position.
6. Provide the patient with educational materials.
Providing the patient with education promotes patient and baby health.
7. Apply gloves, clean the exam room, properly dispose of used supplies, and disinfect or sterilize equipment.
These precautions reduce the risks of cross-contamination.
8. Wash hands and document the visit in patient’s chart.
Careful records must be kept throughout the prenatal and postpartum period.
Measuring the fundal height assists the provider in determining fetal growth.
FIGURE 17-18 Prenatal patients are weighed at each visit.
DOCUMENTATION EXAMPLE:
10-18-XX 0900
Return prenatal visit, pt. is at 25 wks. gestation, BP 120/70, weight 156 lb., pt. reports no problems or concerns, urine negative for glucose and protein. Megan Speck, CMA (AAMA)
Chapter Summary Obstetrics and gynecology is a fascinating specialty. Medical assistants can often be instrumental in helping patients reduce their risks of GYN infections and diseases with proper education. Instituting modesty and explaining what to expect will help to alleviate patient anxiety. The obstetric side of this specialty can be a very satisfying specialty in which to work. The medical assistant is a key member of the obstetric staff and has many responsibilities. Being an active listener and performing accurate testing will assist the provider in keeping mother and baby healthy and safe.
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FIELD APPLICATION CHALLENGE A 27-year-old female is being seen in the office today for her yearly GYN exam. The medical assistant sets up the equipment, obtains needed information from the patient, and instructs the patient to empty her bladder. When the patient is prepared, the provider and medical assistant enter the room for the exam. The provider collects the specimen and places it in the ThinPrep solution. Following the exam, the medical assistant notices that the lid on the ThinPrep container is on crooked. The medical assistant reaches over to reposition the lid and the lid separates from the container, causing the contents to spill all over the floor. A small portion
of the solution is still inside the container and the medical assistant picks up the lid and places it back on the container. The patient just finished checking out but has not left the office yet. 1. Will the test need to be repeated? 2. Would it be best to stop the patient before she leaves the office or call her on the telephone for a new appointment? 3. If you do stop the patient, should you tell her what happened before you tell the provider? 4. How could this incident have been prevented?
Chapter Assessment 1. Another term for labor is: a. parity. b. puerperium. c. partuition. d. postpartum.
6. What can an AFP test detect? a. Neural tube defects b. Intrauterine death c. Cystic fibrosis d. Gender of the fetus
2. Which of the following tests should be performed to diagnose endometrial cancer? a. Pap b. Biopsy c. Maturation index d. Hormone level
7. Ovulation occurs on approximately day _______ of the menstrual cycle. a. 12 b. 10 c. 21 d. 14
3. Which instrument is used to view dysplastic cells of the cervix? a. Laproscope b. Hysteroscope c. Colposcope d. Uteroscope
8. Natural menopause occurs at what age? a. After age 40 b. After age 35 c. 55 d. 50
4. Braxton-Hicks contractions are also known as: a. preterm labor. b. false labor. c. early labor. d. true labor. 5. Pregnancy is divided into three trimesters and lasts approximately how long? a. 40 weeks b. 36 weeks c. 10 months d. 35 weeks
9. Which condition produces irritability and mood swings prior to menses? a. EDD b. EDC c. PMS d. STD 10. Freezing of atypical cells on the cervix is known as: a. LEEP. b. cryosurgery. c. electrosurgery. d. nitrosurgery.
W OM E N ’S H E A LT H I S S U E S : OB S T E T R IC S A N D G Y N E COLO G Y
11. Nagele’s Rule is used to calculate the: a. expected delivery date. b. gestational age. c. fetal weight. d. fetal height.
Web Activities
On your StudyWARE CD-ROM, go to the DVD Challenge for this chapter. View the DVD clip and respond to the following questions: 1. How far should the patient scoot down on the table for a pelvic exam?
2. Search the Web for information on natural childbirth versus epidural childbirth.
2. What did the medical assistant do to the speculum to make insertion more comfortable?
CONNECTION Using your StudyWARE CD-ROM: ❖ Complete the Hangman activity for this chapter. ❖ Complete the Quiz for this chapter in Test Mode.
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THE DVD LINK
1. Visit the Web site for Planned Parenthood and search for community resources for patients who do not have family support.
3. Visit the Web site for the LaLeche League and gather the latest information on breastfeeding.
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3. Besides demographic and insurance information, list four other items that are listed on the lab form when sending a specimen for a Pap test.
C H A P T E R
Urology and Male Reproductive Examinations and Procedures Chapter Outline Types of Providers Who Specialize in Treating Diseases and Disorders of the Urinary and Male Reproductive Systems Patient Screening for the Urinary System Diagnostic Testing Laboratory Analysis Cystoscopy Intravenous Pyelography (IVP) Percutaneous Suprapubic Bladder Aspiration Treatments Involving the Urinary Structures Extracorporeal Shock Wave Lithotripsy Urethral Dilatation Dialysis Kidney Transplant
Patient Screening for the Male Reproductive System Provider Examination Testicular Self-Examination Diagnostic Testing Associated with the Male Reproductive System Transrectal Ultrasound (TRUS) Vasography Biopsy Lab Work Associated with Male Reproductive Organs Common Procedures Performed Involving Male Reproductive Organs Vasectomy TURP Cirumcision Erectile Dysfunction
18 Essential Terms benign prostatic hyperplasia catheterization circumcision cystoscopy dialysis digital rectal exam (DRE) erectile dysfunction (ED) extracorporeal shock wave lithotripsy (ESWL) Foley catheter hemodialysis hernia intravenous pyelography (IVP) nephrologist peritoneal dialysis testicular selfexamination (TSE) transrectal ultrasound (TRUS) transurethral resection of the prostate (TURP) continues
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KEY COMPETENCIES Performing a Catheterization
urethral dilatation urethral orifice urologist urology vasectomy vasography
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ABHES
III.C.3.b.4.f III.C.3.b.2.c
VI.A.1.a.4.h VI.A.1.a.4.j
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Developmental Objectives 1. After completing this chapter, you should be able to: 2. Correctly spell and define the essential terms. 3. List and describe physicians who specialize in treating diseases and disorders of the urinary tract, kidney, and the male reproductive system. 4. List typical screening questions that are used to assess urinary disorders and disorders involving male reproductive organs and structures. 5. Discuss the different types of lab tests that are performed to check urinary health. 6. List and describe common types of diagnostic tests that can be performed to check urinary health. 7. Describe treatments used to treat various disorders involving the urinary tract. 8. 9. 10. 11.
List and describe steps for performing a testicular self-examination (TSE). List common diagnostic and lab procedures associated with men’s health. List three common procedures that involve the male reproductive organs. Describe erectile dysfunction and list testing procedures and treatments used to treat the disorder.
Introduction Promotion of health in the field of urology involves an understanding of structure, physiology, and disease of the urinary system and the male reproductive system. A complete physical exam includes assessment of these functions, often with the assistance of the medical assistant. The medical assistant must be observant for signs or symptoms that might indicate potential pathology. The primary role of the medical assistant in regards to diagnostic procedures is to provide the patient with preparatory instructions, to offer emotional support during testing, and to provide the patient with education following the procedure. The medical assistant may also perform urinary catheterizations after instruction by the provider. Both male and female catheterization techniques require an accomplished level of skill.
TYPES OF PROVIDERS WHO SPECIALIZE IN TREATING DISEASES AND DISORDERS OF THE URINARY AND MALE REPRODUCTIVE SYSTEM The primary care provider often treats minor infections and conditions involving the urinary tract and male reproductive system. When symptoms are more complex, the patient may be referred to a urologist, a provider who specializes
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in treating diseases and disorders of these two systems. A nephrologist is a provider who specializes in treating diseases and disorders of the kidneys. The medical assistant is often responsible for preparing patients for these types of exams and for assisting the provider during the exam.
PATIENT SCREENING FOR THE URINARY SYSTEM Medical assistants may have the responsibility of screening patients prior to provider examination or over the phone. The depth of screening will be established by office protocol, but in general medical assistants should be able to ask a series of questions related to the patient’s symptoms. Table 18-1 lists types of questions that are typically asked during urinary screenings and lists common procedures that coincide with symptoms. Important note: Medical assistants should never perform any procedure unless directed to do so by the provider; however, they can set up various equipment and supplies to help save time in the event that testing is ordered.
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FI E L D S M A R T S Providers often use a variety of terms to describe urine or urine flow. ❖ Oliguria refers to scanty urination. ❖ Polyuria refers to passing large amounts of urine. ❖ Nocturia refers to the need to urinate during normal hours of sleep or urinating frequently during the night. ❖ Urgency refers to an immediate need to urinate. ❖ Incontinence refers to an inability to retain urine. ❖ Dysuria refers to difficult or painful urination. When writing a patient’s complaint, use the common terms provided by the patient. Only use the above technical terms when in the presence of the provider. The patient will not understand these terms unless the patient is in the health care industry.
DIAGNOSTIC TESTING A variety of diagnostic tests may be ordered to evaluate the health of the urological system. Medical assistants should familiarize themselves with all tests requiring involvement and how to instruct the patient on the TABLE 18-1 Patient Screening and Instructions for the Urinary System ASK THE PATIENT: “ARE YOU EXPERIENCING ANY. . .”
Pain upon urination, increase in urination, need to urinate at night, immediate need to urinate, weak or unsteady stream, inability to completely empty your bladder, a loss in force of your urine stream, changes in urine volume, bedwetting, lower abdominal or lower back pain, fever, vaginal or penile symptoms? Any history of urinary disease?
DISROBING INSTRUCTIONS
Disrobe from the waist down
VITAL SIGNS
All
EQUIPMENT
Pelvic tray, STD cultures, catheter tray, clean catch container, urinary dipsticks, UA, microscopic supplies, culture supplies, urethral dilatators, lubricating gel, 4x4s
POSSIBLE PROCEDURES
Pelvic exam if vaginal symptoms are present, penile exam if penile symptoms are present, catheterization if the patient is unable to void or when a sterile specimen is absolutely necessary, UA and culture if urinary symptoms are present, urethral dilatation if the patient has urethral constriction
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preparation and expectations of the diagnostic tests. Patient education is crucial for the highest level of patient compliance.
Laboratory Analysis Laboratory tests are important in the evaluation of urological health. Blood tests and urine tests may provide indications that pathology is present. A complete analysis of the urine involves physical, chemical, and microscopic examination. In order to obtain accurate results, the medical assistant must ask the patient to collect a clean catch urine specimen. A clean catch specimen means that the patient has cleaned the vaginal or penile openings to rid the area of sloughing cells and microorganisms that may contaminate the urine sample. The medical assistant must give clear instructions so that the patient understands how to properly collect the sample. Chapter 27 includes a procedure for obtaining a clean catch urine sample and includes procedures for performing a urinalysis. Blood tests are also performed to determine the health of the kidneys. Blood, urea, nitrogen (BUN), creatinine, uric acid, and blood protein levels are all tests that are used to evaluate renal function. If any of these tests are elevated, further diagnostic testing may be indicated.
Catheterization Some laboratory analyses require a sterile urine specimen, which must be obtained by catheterization. This
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FI E L D S M A R T S As a medical assistant, you are often responsible for calling results to a patient. This generally prompts questions. It is not your responsibility to interpret lab results for the patient or to place any diagnosis on the lab values. You should never go beyond what the provider has approved to be shared with that patient. Patients wanting more information than that which was originally approved should be connected to the provider.
process involves the insertion of a sterile tube directly into the bladder through the urethra using strict sterile technique. The medical assistant may assist the provider or may actually perform the procedure themselves. (Note: Check state laws for any restrictions on medical assistants performing catheterization.) Two common types of catheters are used to perform catheterizations, straight catheters and Foley catheters (Figure 18-1). Straight catheters are used for obtaining a single specimen and then discarded. They may also be utilized by the urologist for conditions, such as paralysis, that might cause urinary retention in the bladder. Removing urine via a straight catheter will help eliminate bladder distention and discomfort (refer
One of the more common conditions that warrants lab testing is a urinary tract infection. Some general guidelines for prevention of cystitis, or bladder infection, and kidney disease include: ❖ Drink plenty of fluids. Cranberry juice is often reported to help by keeping the pH of the urine acidic, which does not provide a suitable environment for bacterial growth. Be cautious of excessive sugars in drinks. Some juices have added sweeteners. ❖ Urinate when needed and urinate completely. ❖ Cotton underwear is helpful in that it does not trap excessive moisture.
❖ Urinate after intercourse. ❖ Use good hygiene skills. For women, when wiping, go from front to back. This prevents fecal contamination. ❖ Avoid any fragrance soaps or bubble baths that might irritate the urethra. ❖ If using a diaphragm for birth control, remove it when not in use. If chronic UTIs occur, a prophylactic or preventive antibiotic may be ordered by the physician to reduce the patient’s risk of infection.
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TOOL BOX Foley catheter
FI E L D S M A R T S Inserting a catheter is often a delicate and embarrassing procedure for an adult. Remember to provide privacy along with emotional support. Consider the gender of the patient you are catheterizing, along with the level of discomfort for the patient. There may be an indication for you to allow another health professional of a different gender to perform the procedure.
Straight catheter
FIGURE 18-1 Types of catheters: straight and Foley
to Procedure 18-1). The catheter tubing is inserted into the urethral orifice (the opening through which urine is eliminated from the body), through the urethra, and into the bladder. Refer to Figure 18-2 for pictures of the female and male genitalia and urinary tract to become familiar with the correct landmarks for catheterization. Foley catheters have a balloon that inflates to keep the catheter in place for an extended period of time. This type is useful for obtaining a 24-hour collection
from a patient who may not be able to understand and follow the directions for obtaining such a specimen. These are also used for patients during and following surgery or for those on a medication that causes them to be incontinent. A Foley catheter may also be used for other urological difficulties that affect urine control.
Cystoscopy Following the initial patient assessment, inspection, palpation, and laboratory analysis, the provider may Mons pubis
FIGURE 18-2 (a) A cross section of the male anatomy illustrating the urethra and bladder (b) The female genitalia (c) A cross section of the female anatomy illustrating the urethra and bladder
Clitoris
Symphysis pubis Labia majora
Prepuce of clitoris Glans of clitoris
Labia minora
Urethral orifice Hymen Vaginal
Anus Coccyx
(b)
Vas deferens
Bladder
Urethra Uterus Urinary bladder
Glans penis Rectum Scrotum
Urethral orifice
Anus
Epididymis
Vaginal orifice
Testis
(a)
(c)
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want to inspect the interior of the urethra and bladder. This can be accomplished by a test called cystoscopy (Figure 18-3). This procedure involves the insertion of a thin scope with a light into the urethra, which is then directed into the bladder. The physician can visualize and examine the pathway for any abnormal pathology that could include tumors, stones, infection, and bleeding. The medical assistant may be responsible for patient preparation and patient education, and therefore should understand the importance of asking the proper pre-and post-procedural questions and educating the patient about which complications to look for and when to report these to the provider.
Light cord Urinary bladder
Percutaneous Suprapubic Bladder Aspiration At times, a Foley or straight catheter is not able to be inserted through the urethra, and yet, entry into the bladder is necessary. After the medical assistant pre-
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Cystoscope (a type of endoscope)
Water cord
Light
Prostate gland
Rectum
Intravenous Pyelography (IVP) Intravenous pyelography (IVP) is an x-ray examination using dye (contrast) that is injected intravenously. The medical assistant should understand the indications and rationale for performing an IVP (Table 18-2).
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FIGURE 18-3 A cystoscope is inserted through the urethra into the bladder.
pares the suprapubic region for a sterile procedure, the provider inserts a 22 to 23 gauge, 31⁄2 inch needle (spinal needle) above the pubic symphysis into the urinary bladder (a smaller size needle would be used for
When giving a patient instructions for cystoscopy, first ask the following pre-procedure questions: 1. Are there any allergies, including those to anesthetic agents? (Rationale: Local, spinal, or general anesthesia may be used. Past history of difficulties needs to be documented.) 2. Are there any bleeding problems or bloodthinning medications being taken? 3. Might the patient be pregnant? 4. Are there any other concerns that need to be discussed with the provider? Reinforce any directions given by the provider. Depending on the type of anesthesia, clarify that the patient understands directions regarding food and drink. Local anesthesia may not be affected by intake, while general anesthesia is usually NPO (nothing by mouth) for at least eight hours prior to the test. Also, prophy-
lactic antibiotics may be prescribed to prevent urinary tract infections. It is imperative that the patient understands the importance of taking the antibiotics as prescribed both before and following the procedure. After the procedure, provide the patient with the following post-procedure instructions: 1. A urinary tract infection may occur. Indication will be pain or burning with urination, urgency, frequency, dribbling, foul-smelling urine, or pain in lower abdomen. Any signs or symptoms of a UTI including a fever need to be reported immediately. 2. A pinkish tint to the urine following the procedure is normal. This should only persist for a few days. 3. Increasing fluids after cystoscopy is important to stress. This may help prevent complications.
Copyright 2009 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
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TABLE 18-2 Preparing for the IVP Why is an IVP ordered/ performed?
Blood in the urine Flank pain A tumor in the urinary tract Location of kidney stone A recurring UTI An accident/injury to the area
Information necessary to know prior to the IVP
Pregnant An IUD in place Allergies to dye, iodine Any allergic reactions X-rays using barium within the last four days A history of kidney problems or diabetes
Patient education topics
NPO 8 to 12 hours prior to IVP If breast feeding, use formula for two days following the procedure. Do not wear any jewelry to the test. You may feel flushing or burning from the dye. Weakness, nausea, or lightheadedness may be normal shortly after the test. Drink plenty of fluids after the test to flush the contrast material from the body.
infants and small children). Urine can then be withdrawn into the 20 mL syringe. The technique is illustrated in Figure 18-4. Indications for this procedure may include: ❖ Insertion of medication directly into the bladder ❖ Obtaining a sterile urine specimen ❖ Relief of urinary retention This procedure is sometimes performed on small children to obtain a sterile specimen when a UTI is suspected. The medical assistant should assist with maintaining a sterile environment while providing patient and parental support. Refer to Chapter 24 for preparing and maintaining a sterile environment.
TREATMENTS INVOLVING THE URINARY STRUCTURES Treatments that are used for disorders and diseases involving the urinary tract and kidneys are contingent on the patient’s exact condition and the amount of damage present. Patients with urinary tract infections often are treated with antibiotic therapy. If a patient’s infection is the result of stricture in the urethra, the provider may need to perform a urethral dilatation. Patients whose kidneys are shutting down may need dialysis or a transplant to survive.
FIGURE 18-4 Suprapubic aspiration
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F IEL D S M A R T S Procedures and tests are constantly changing in the field of medicine and you must remain current with the changes. Although you may not actually perform some of the procedures, your provider will want you to be able to schedule the procedure and provide proper patient education. You may also be called upon to assist with the test. Remember that patients under stress often forget instructions they received. This often prompts a call to the office. Be prepared to answer their questions. This will save time for you and your provider in the long run.
Extracorporeal Shock Wave Lithotripsy Patients often enter the ER complaining of a sudden onset of severe back pain and blood in their urine. These symptoms are quite often seen in patients with kidney stones. There are a variety of treatments for this condition, including: administration of analgesics and straining of the urine for several hours to days following onset of the symptoms; removal of the stone through surgical intervention; and a procedure known as extracorporeal shock wave lithotripsy (ESWL). ESWL uses shock waves to break the stones down into small particles so that they can pass through the urinary tract with more ease. This treatment is usually performed in a hospital setting.
Urethral Dilatation Urethral dilatation is a procedure in which the urethra is dilated with graduated dilators (pictured in Chapter 22) due to stricture. Urethral stricture is a narrowing of the tube that leads from the bladder to the outside of the body. This condition often results in excruciating pain upon urination, and may also be the source of repeated infections due to urine reflux caused from narrowing of the urethra. This procedure should be performed using strict sterile technique. A break in sterility could lead to a severe urinary tract or kidney infection.
Dialysis Today, there are many patients suffering from end-stage renal disease due to complications from other diseases, such as diabetes, while others have kidneys that are
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badly damaged from autoimmune diseases and other conditions that directly affect kidney function. When the kidneys can no longer perform their function of filtering the waste products from the blood, patients must undergo a process known as dialysis. There are two main types of dialysis: hemodialysis and peritoneal dialysis.
Hemodialysis During hemodialysis, the patient is hooked up to a machine (Figure 18-5) by tubes that connect to the blood vessels. The blood is slowly pumped through a filter or dialyzer where waste products and extra fluid are removed and the blood is then returned back to the body. One session of hemodialysis can last anywhere from three to five hours and must be performed in a dialysis center. This type of dialysis changes a patient’s life because of the time commitment required. In order to be attached to a dialysis machine, the provider must fashion a site where the blood can flow in and out of the body. There are basically three types of access for hemodialysis: ❖ Venous catheter/port: This type of access is usually only used temporarily. A tube is placed in one of
FIGURE 18-5 A dialysis machine filters waste products from the blood of patients whose kidneys have failed.
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the veins of the neck, chest, or groin (Figure 18-6). The port can easily become clogged and can be a site for the development of infection. ❖ Fistula: This type of access is created by connecting an artery and a vein in the lower arm. The fistula does not clot as easily as the venous catheter and is considered to be the most durable dialysis access (Figure 18-7a). ❖ Graft: This type of access is created by implanting a tube under the skin of the arm, which serves as an artificial vein. Grafts also have problems with clotting and infection and need to be replaced frequently (Figure 18-7b).
(a) Arteriovenous fistula
Peritoneal Dialysis (b) Arteriovenous vein graft
Peritoneal dialysis can be performed at home and even while the patient sleeps, so many patients opt for this method of treatment. The process of performing peritoneal dialysis is known as an “exchange” and four
FIGURE 18-7 Examples of (a) a fistula and (b) a vein graft
FIGURE 18-6 Access ports for dialysis may be inserted into the
to six exchanges are completed each day. Dialysis fluid is fed through a tube placed into the patient’s abdomen. The process includes three steps:
subclavian or jugular vein.
Jugular vein Subclavian vein
1. The fluid enters the body through a tube into the peritoneal cavity (Figure 18-8). 2. Wastes and extra fluid are filtered across the peritoneal membrane and enter the dialysis fluid. 3. The dialysis fluid is then drained after several hours and replaced with new fluid. Once the new fluid enters the peritoneal cavity and the bag is empty, it can be rolled (Figure 18-9) and hidden underneath the clothing. There are three types of peritoneal dialysis and patients may choose the one that best fits their lifestyle:
Subclavian vein
❖ Continuous ambulatory peritoneal dialysis (CAPD): Fluid remains in the abdomen anywhere from four to six hours and then is exchanged for fresh fluid. The patient will perform the exchange four times a day. This is the most common type of peritoneal dialysis used. ❖ Continuous cycling peritoneal dialysis (CCPD): This type of dialysis requires a machine that fills and drains the dialysate fluid from the abdomen. This method takes 10 to 12 hours to complete so it is performed at night while the patient sleeps. ❖ Intermittent peritoneal dialysis (IPD): This type of dialysis is usually performed in a hospital or dialysis center with the exchange taking up to 24 hours and performed several times per week. For this reason, this type of dialysis is rarely used anymore.
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Peritoneal dialysis solution
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FI E L D S M A R T S Peritoneal cavity Catheter Catheter adapter
When working with dialysis patients, symptoms such as headache, weight gain, edema, thirst, and confusion are very important. Electrolytes are commonly affected and must be continually monitored. Patients exhibiting any of these symptoms should be evaluated immediately (usually in the ER) for electrolyte abnormalities.
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PATIENT TUTOR FIGURE 18-8 The tube is inserted into the patient’s peritoneal cavity.
The provider will explain the risks and protocols regarding transplantation. Reinforcing the concepts will usually be the medical assistant’s responsibility. Remind the patient that an immunosuppressant will be taken indefinitely. This weakens the immune system; therefore, the patient will be more susceptible to infection. For transplant patients, always review methods for prevention of disease transmission.
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C R I T I C A L T H I N K I NG CHALLENGE
FIGURE 18-9 An empty dialysate container can be rolled down to make it less noticeable under the clothing.
A 30-year-old female patient who is on dialysis calls to say that she has gained three pounds in the last two days and that she is just feeling “weird.” 1. What could be wrong with this patient? 2. What course of action would be appropriate for this scenario?
Kidney Transplant Many patients find dialysis a difficult process to maintain long term and opt for a kidney transplant. Transplantation involves removing a diseased or damaged kidney and surgically replacing it with a donor kidney, either from a living donor or a deceased patient. Much preparation and instruction is involved, prior to the surgery and postoperatively. Certain criteria are necessary to become a recipient, as the waiting list can be long.
❖ End-stage kidney disease must be determined. No other methods of treatment will correct the kidney problem. ❖ The patient must not have an active infection. ❖ The patient should not have another life shortening condition such as cancer or lung disease. ❖ Age may be a consideration.
Copyright 2009 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
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Postoperatively, the patient will be on medications to prevent rejection of the organ. This is accomplished by suppressing the immune system, which would determine that the kidney is a foreign body.
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C R I T I C A L T H I N K I NG CHALLENGE Mr. Smith, a 74-year-old patient, comes to the office for the first time. He proves to be a good historian when questioned about prior illnesses and surgeries. After obtaining Mr. Smith’s vitals and listing his current medications, he tells you that he is having trouble, “you know, down there.” Comfort levels are obviously an issue since Mr. Smith is vague and possibly afraid to use specific terms. 1. How would you handle this situation? 2. What types of questions would you ask Mr. Smith?
PATIENT SCREENING FOR THE MALE REPRODUCTIVE SYSTEM Before the provider examines the patient, the medical assistant should take the patient’s chief complaint and perform vital signs. Initial interactions and questions during the screening process must ensure patient confidentiality and comfort, which will create an environment for open and honest communication. Important in any assessment or screening is the development of a successful professional relationship between the patient and all health care providers. Always communicate at the level of the patient’s ability to understand. Table 18-3 lists types of questions that are typically asked during screenings involving the male reproductive organs and common procedures that coincide with symptoms. Important note: Medical assistants should never perform any procedure unless directed to do so by the provider; however, they can set up various equipment and supplies to help save time in the event that testing is ordered.
Provider Examination Inspection by the provider during the physical exam involves visual examination of the external genitalia of the patient. Lesions, drainage, rashes, and inflamma-
tory signs should be noted. When examining a male, the provider will carefully look at the skin of the penis, the prepuce or foreskin, and the glans. The pubic hair can be examined for lice. Normally there should be no discharge noted through the urethral meatus. If there is a discharge, this can be examined on a slide under a microscope, or cultured for evaluation. The medical assistant may be assigned preparation of the slide or culture. In addition to the penis, the scrotum should be inspected by the provider, to include the skin, the posterior surface, and any swelling or excessive veins. Bulges might also be noted, which could indicate a hernia, either inguinal or femoral. Hernias are the protrusion of a body part though a surrounding
TABLE 18-3 Patient Screening and Instructions for the Male Reproductive System ASK THE PATIENT: “ARE YOU EXPERIENCING ANY. . .”
Pain upon urination or problems emptying your bladder? Loss in force of your urine stream, changes in urine volume, blood in your urine? Bedwetting, lower abdominal or lower back pain, fever, penile discharge, itching, or odor? Swelling in or around the testicle area? Are you sexually active? Are you experiencing any problems holding an erection or any pain during intercourse? Are you performing testicular self-examinations? If so, how often?
DISROBING INSTRUCTIONS
Disrobe from the waist down
VITAL SIGNS
Blood pressure, temperature
EQUIPMENT
Clean catch container, STD cultures, if indicated
POSSIBLE PROCEDURES
Complete urinalysis (for urinary symptoms), culture and sensitivity (for urinary symptoms), STD cultures (for penile symptoms)
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F IEL D S M A R T S The tray setup for a digital rectal exam (DRE) includes 4x4s, water soluble lubricant, and possible occult blood test supplies under special conditions.
area into a body cavity, creating the observed bulge. Figure 18-10 illustrates an inguinal type with a portion of the intestine protruding into the scrotal sac. The provider may conclude the exam with a digital rectal exam (DRE). During this part of the exam, the provider will insert a gloved finger into the rectum and feel the prostrate for enlargement, lumps, or any other abnormalities. Patients may be especially anxious regarding this part of the exam and ask several questions prior to the exam. Reassure patients that are particularly nervous and share the patient’s anxiety with the provider.
Testicular Self-Examination Early detection of testicular cancer involves understanding the methods for testicular self-examination
Intestine
FIGURE 18-10 An inguinal hernia
(TSE). The medical assistant may be called upon to provide information on the correct steps for performing TSE. Provide the patient with an instruction card such as the one in Figure 18-11.
FIGURE 18-11
Testicular Self-Examination
Testicular self-examination should be performed once a month after a warm bath or shower. The heat will relax the scrotum, making it easier to find abnormalities. (A) Stand in front of the mirror. Look for swelling on the skin of the scrotum. (B) Examine each testicle with both hands. Position your index and middle fingers under the testicle with the thumbs on top. Gently roll the testicle between your thumbs and fingers. (Having one testicle larger than the other is normal.) (C) Find the epididymis (the soft, tubelike structure and the back of the testicle). Do not mistake the epididymis for an abnormal lump. (D) If you find a lump, notify your doctor right away. Most lumps are found on the sides of the testicle, but some are located on the front. Testicular cancer is highly curable when detected early and treated promptly.
(A)
(B)
Vas deferens
Epididymis
Epididymis
Testicle Nodule
(C)
(D)
Instructions for TSE
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It is important to stress the necessity for regular self-examination. Any abnormalities should be reported immediately for further evaluation. Testicular cancer is one of the most curable forms of cancer with over a 90% cure rate due to early detection. A testicular exam may be performed by a provider but a TSE is imperative for early detection. Steps involved in TSE include: ❖ Perform the examination on a monthly basis. ❖ Perform the examination following a warm shower. This will relax the scrotum, making it easier to find abnormalities.
DIAGNOSTIC TESTING ASSOCIATED WITH THE MALE REPRODUCTIVE SYSTEM There are a limited number of diagnostic tests involving structures of the male reproductive tract. Some of the more popular tests are listed below.
Transrectal Ultrasound (TRUS) Ultrasound procedures use reflected sound waves to produce pictures of internal body parts. During transrectal ultrasound (TRUS), an ultrasound probe is inserted into the rectum to produce images to examine the prostrate in men suspected to have benign prostatic hyperplasia (enlargement of the prostate). The procedure is often used after the prostate is already determined to be enlarged. If a high prostate specific antigen (PSA), a blood test to check prostate health,
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F IEL D S M A R T S African-American males, men with high cholesterol, men that drink large amounts of alcohol, and men with a family history of prostate cancer are at greater risk for prostate cancer than other groups.
❖ Examine the testicles in front of a mirror. Note any unusual swelling of the scrotum. ❖ Use both hands to examine each testicle and position the hands so that the thumbs are on the top side of the testicle and the index and middle fingers are on the posterior portion of the testicle. ❖ Slide the fingers back and forth while holding on to the testicle, checking for any lumps. (Inform the patient that he may feel the tube-like structures of the epididymis. This is normal.) ❖ Report any lumps immediately.
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has been identified and a biopsy is required, the TRUS may guide the location of the needle for the biopsy. Other indications for TRUS are: ❖ Estimation of prostate size ❖ Evaluation of lumps that are detected with a physical exam ❖ Evaluation of the vas deferens ❖ Evaluation of the seminal vesicles ❖ Evaluation of the ejaculatory duct
Vasography Vasography is a radiological procedure that is used to evaluate patency (openness) of the vas deferens and ejaculatory ducts. A contrast material is injected into the vas deferens and radiographs are taken as the dye flows through the ducts.
Biopsy Biopsy involves the surgical removal of tissue to determine if cancerous cells are present. Biopsies may be taken of any of the structures within the male reproductive system during TRUS procedures or special types of vasography procedures.
LAB WORK ASSOCIATED WITH MALE REPRODUCTIVE ORGANS Common lab work associated with the male reproductive organs includes:
U R OLO G Y A N D M A L E R E P R OD U C T I V E E XA M I N AT IO N S A N D P R O C E D U R E S
❖ Semen analysis to measure sperm count and motility for infertility studies ❖ Hormone levels to detect infertility and glandular conditions ❖ Prostate-specific antigen (PSA) for prostate health
COMMON PROCEDURES PERFORMED INVOLVING MALE REPRODUCTIVE ORGANS Common procedures performed on structures within the male reproductive tract include vasectomy, the TURP procedure, and circumcision.
Vasectomy Vasectomy is a surgical procedure in which the vas deferens is cut, clamped, or sealed to prevent sperm from entering the ejaculate. It should be considered to be a permanent form of birth control, although there are now techniques for vasectomy reversal. Vasectomies (Figure 18-12) are usually performed in the provider’s office and take approximately 20 to 30 minutes to complete. The medical assistant sets up all the equipment and often assists the provider with the procedure. Patients are often apprehensive and need to be told what they can expect before, during, and following the procedure. The medical assistant may explain the procedure as follows:
FIGURE 18-12 The vas deferens is separated and sealed during a vasectomy.
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❖ The scrotum is cleaned with an antiseptic and shaved if necessary. ❖ The patient is given an oral or IV medication to relax and relieve anxiety. ❖ A local anesthetic is injected into the surgical area. ❖ One to two small incisions are made in the scrotum and the vas deferens is pulled through the incision, cut, and then sutured, tied, or sealed by electrocautery. ❖ The vas deferens is placed back inside the scrotum and the skin is closed with dissolvable sutures. There are other methods of performing vasectomies that differ from the traditional method, including: ❖ The no-scalpel method: This method uses a small clamp instead of a scalpel. The clamp is poked through the skin to retrieve the vas deferens. The vas is then cut and replaced, and the site is sealed. This method takes approximately 10 minutes and there is less healing time. ❖ Vasclip implant: In this method, the vas deferens is not cut, sutured, or cauterized. Instead, it is locked closed with the Vasclip device. There appears to be less pain with this method, but some studies have indicated that it may not be as effective as other methods. Refer to the Patient Tutor tool box on this page for postop instructions to be given to the patient.
TOOL BOX
PATIENT TUTOR Vas deferens
Epididymis
Glans penis Testis
Scrotum
Patients must strictly adhere to the following postop instructions to prevent complications from developing: ❖ Lie on your back and apply ice packs to the area for the remainder of the day. ❖ Expect some swelling and minor pain for several days. ❖ Return to work in one to two days, depending on your job duties. ❖ Avoid heavy lifting until healed. ❖ You may resume sexual activity after one week, if comfortable. ❖ Use contraception. You may still impregnate your partner until your sperm count is zero.
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PA TIEN T P E R SP E C T I V E
C R I T I C A L T H I N K I NG CHALLENGE
Making the decision to have a vasectomy was very difficult! My wife and I battled over this decision for the last five years. I am not worried as much about the pain as I am about the embarrassment factor. I am just very private and feel very uncomfortable having my private area exposed during the procedure.
Refer to the Patient Perspective tool box on this page and answer the following questions. 1. What kinds of things can the medical assistant say to the patient to help ease the patient’s fears? 2. When possible, would it be better to have a male assist with this procedure? Why? 3. Should the medical assistant share the patient’s feelings with the provider?
TURP Transurethral resection of the prostate (TURP) is a procedure performed on males that have benign prostatic hypertrophy (BPH). In this procedure, the surgeon cuts away overgrown tissue of the prostate to facilitate urination (Figure 18-13). This may be performed as an inpatient or outpatient procedure.
Circumcision Circumcision is a procedure in which the prepuce or foreskin of the penis is cut away. It is usually performed within one to two days following birth, but may also be performed in the office when the infant is a little older. The medical assistant may be responsible for setting up the circumcision tray, obtaining the anesthetic,
FIGURE 18-13 An illustration of what occurs during a TURP procedure Bladder Resectoscope
Enlarged prostate Cut pieces of prostatic tissue
Rectum
and restraining the infant by placing him on a papoose board. Males that were not circumcised as infants may decide to have this procedure performed later in life for religious or physiological reasons.
ERECTILE DYSFUNCTION Erectile dysfunction (ED), or male impotence, is defined as the inability of a man to achieve and maintain an erection during sexual intercourse. About 50% of men between the ages of 40 and 70 have some form of ED. The causes of ED may be physiological or psychological and include diabetes, hormonal deficiencies, neurological disturbances, vascular disease, and particular medications. Evaluation tools that may be used to determine the diagnosis or cause of the disorder include lab work to test hormone levels (testosterone, prolactin, and thyroid), glucose level (for diabetes), and other related chemicals. Ultrasound may be used to check the health of the penile arteries as a possible source for ED. Another test, nocturnal penile tumescence (NPT), may also be performed. In this test, a pair of special gauges is attached to the patient’s penis before he goes to sleep. Males normally have erections throughout the night during periods of rapid eye movement (REM). If the patient has no erections, it may indicate physiological causes for the ED. If the patient does have erections, it may indicate that the reason for the ED is psychological. This test previously had to be performed in a sleep center but now can be performed in the privacy of the patient’s home with a special unit.
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Prostate cancer is very common in men over the age of 65. It occurs due to an abnormal growth of cells in the prostate gland. The cause of this disease is unknown, but it appears that age, family history, race, and eating a high fat diet can increase a male’s chances of developing the disease. It is very slow-growing and highly curable. While it does not usually cause symptoms in the early stages, the first sign the patient may notice is problems with urination. Other symptoms may include: ❖ ❖ ❖ ❖
Difficulty starting the urine stream Weaker than normal stream Not being able to urinate at all Frequency
Treatments for ED include medications such as Sildenafil (Viagra®) and Yohimbine (Trazadone®). The patient may opt to use self-injections, in which the patient injects the side of his penis with a medication that produces an erection, or a urethral suppository that assists in producing an erection. A vacuum constriction device may also be used to produce an erec-
❖ ❖ ❖ ❖ ❖
Retention Nocturia Dysuria Hematuria Pain deep in the lower back, abdomen, hips, or pelvis
Prostate cancer may be suspected following a physical exam. If so, the provider will order a blood test to measure PSA, which is usually increased in patients with this type of cancer. However, the only sure way to diagnose prostate cancer is by performing a biopsy. Treatment involves surgery or radiation to remove or destroy the cancer, which unfortunately can leave the patient impotent.
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PAT I E N T T U T O R
tion. A soft rubber ring is placed at the base of the penis, helping the penis to stay erect during the sexual encounter. Because of the sensitivity issues involved with ED, the medical assistant must be empathetic and demonstrate a professional demeanor when discussing symptoms or treatment associated with this condition.
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PROCEDURE 18-1 Urinary Catheterization Objective: To obtain a sterile urine specimen by inserting a sterile catheter into the bladder while observing strict sterile technique.
Equipment/Supplies: ❖ Sterile gloves ❖ Sterile disposable catheter kit (includes drapes, sterile wipes or sterile cotton balls, sterile catheter, gauze, antiseptic cleanser, sterile lubricant)
❖ Sterile specimen container with lid
PROCEDURAL STEPS
RATIONALE
1. Identify the patient using two identifiers, identify yourself, and explain the procedure.
Using two identifiers will prevent performing the procedure on the wrong patient and explaining the procedure will help the patient know what to expect.
2. Wash your hands and assemble the supplies. Place the catheter kit on the Mayo stand or a nearby counter surface.
Washing hands is an effective way to prevent from spreading microorganisms to other patients.
3. Have the patient remove clothing from the waist down and provide a drape.
The patient will appreciate the extra modesty.
4. Position the patient in a comfortable dorsal recumbent position and drape with a sheet exposing only the external genitalia.
This position provides the visualization necessary for the procedure, and helps the patient to relax.
5. Place the catheter kit near the working area on the examination table. Open the external covering of the catheter kit. (The inside of the outer covering of the kit will now become a sterile field.)
The catheter kit needs to be near the working area so the supplies are accessible.
6. Carefully reach inside the kit without contaminating the field or contents of the kit and place the waterproof sterile drape from the kit underneath the penis for a male patient (Figure 18-14a), or underneath the buttocks for a female patient. Touch only the corners of the drape.
The waterproof drape will keep the patient and the patient’s surrounding clothes from becoming wet.
7. Wash hands and put on sterile gloves, using caution not to contaminate gloved hands. (From this point on, you will touch only the sterile materials inside the kit and the surface to be catheterized. If anything outside the kit is needed, ask for assistance.)
Touching anything outside the kit will contaminate the sterile field and could prove harmful to the patient.
8. Open the fenestrated drape and place the drape over the external genitalia (Figure 18-14b).
The drape provides extra modesty for the patient and helps to focus on the working area.
(a)
(b)
FIGURE 18-14 (a) Place a sterile waterproof drape underneath the male patient’s penis to keep the patient from getting wet. (b) Place the fenestrated drape over the penis.
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PROCEDURAL STEPS
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RATIONALE
9. Prepare a cleaning solution (either sterile wipes or sterile cotton balls with an antiseptic cleanser) and squirt some lubricant onto the sterile gauze pad.
The cleansing wipes or cotton balls must be prepared prior to starting the procedure; once you start the procedure, you will have no free hands.
10. Insert the tip of the catheter into the sterile lubricant and leave the catheter on the sterile field until ready for use. Open the specimen container and place within reach.
Lubrication will provide easier insertion.The catheter tubing is not very long, so the specimen container must be nearby to receive the urine.
11. For a female, spread the labia with one hand and cleanse the genital areas (right side, left side, and middle) from front to back with the other hand. For males, cleanse the urinary meatus in a circular motion working from the center outward (Figure 18-15). Repeat two more times.
Wipe only from front to back once per wipe. This will prevent contamination to the area. Keep the labia spread in order to prevent contaminating the sterile area. Note: The hand holding the labia open is no longer sterile.
12. Insert the lubricated tip of the catheter slowly into the urethral meatus as seen in Figure 18-16. Proceed slowly and do not force the catheter in. If an obstruction is noted or pain or bleeding is present, stop the insertion.
Forcing the insertion could cause damage to the area and result in later complications.
13. Progress the catheter into the bladder until urine flows. Collect the initial stream in a basin (Figure 18-17), and then obtain the sample in the specimen container.
The initial urine may contain bacteria. Midstream is a better specimen for accurate analysis.
14. After adequate collection, empty the remainder of the urine inside the bladder into the basin. Never leave the bladder partially full after a catheterization.
Leaving the bladder partially full could be uncomfortable for the patient.
FIGURE 18-15 Scrub the tip of the penis with an antiseptic cleanser before inserting the catheter.
FIGURE 18-16 Insert the catheter into the urinary meatus.
15. Slowly remove the catheter from the meatus and place on the table. 16. Clean the genital region if needed.
FIGURE 18-17 Collect the first urine stream into a basin.
17. Remove gloves and wash hands. Assist the patient into a sitting position.
It may be difficult for the patient to sit up following this procedure.
18. Discard the materials in the appropriate waste containers.
Following biohazard guidelines can prevent cross-contamination.
19. Label the container and attach a lab requisition form that has been filled out with all pertinent information.
An improperly documented requisition form could delay testing and treatment. continues
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continued
PROCEDURAL STEPS 20. Document the procedure on the patient’s record. Include any adverse reactions from the patient.
RATIONALE Thorough and accurate documentation is essential for continuity of care.
DOCUMENTATION EXAMPLE:
10-14-XX 2:30 p.m.
Catheter inserted without difficulty using sterile technique per Dr. Rokowski. Urine clear and light yellow, odor: none, Amt: 200 ml. To lab for bacterial culture. Pt. tolerated procedure well. Helen Chung, CMA (AAMA)
Chapter Summary It is important to keep abreast of new developments in diagnosis and treatment in the field of urology. This specialty presents unique problems and even some that can be very embarrassing for the patient. Medical assistants are expected to have a good knowledge base about the diseases and disorders treated in this type of practice and to be able to communicate with and educate patients about their conditions, preparation for procedures, and the procedures themselves.
FIELD APPLICATION CHALLENGE While being examined by the provider, Mr. Jenson appears uncomfortable that you are in the room. He is complaining of painful urination and frequency. The provider tells him you need to get a urine specimen from him. He becomes agitated and yells “NO!” Think about and discuss what actions you might take.
1. Should you insist? 2. Is he able to obtain it himself with thorough teaching? 3. How might you best get a urine specimen without alarming the patient?
Chapter Assessment 1. Patient screening includes observation of: a. colors. b. odor. c. communicated symptoms. d. all of the above.
2. Insertion of a tube to obtain urine is: a. IVP. b. catheterization. c. CT scan. d. clean catch urine specimen.
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3. Measures to prevent bladder disease include: a. limiting fluid intake. b. wiping back to front. c. urinating when needed and urinating completely. d. using perfumed soap. 4. Which of the following terms describes excessive urination? a. Polyuria b. Hematuria c. Nocturia d. Dysuria 5. An x-ray examination using dye (contrast) that is injected intravenously is referred to as an: a. IUP. b. IVP. c. IUD. d. IVD.
Web Activities 1. Search www.webmd.com for information on STDs. Become familiar with signs and symptoms, methods of transmission, and current treatments. New diseases are being studied and reported.
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2. Go to the Web site for the American Cancer Society, www.cancer.org, and review the screening recommendations for prostate cancer. Explore the current treatments, including alternative medicine options.
CONNECTION Using your StudyWARE CD-ROM: ❖ Complete the Concentration activity for this chapter. ❖ Complete the Crossword Puzzle activity for this chapter. ❖ Complete the Quiz for this chapter in Test Mode.
C H A P T E R
Evaluation and Care of the Pediatric Patient Chapter Outline Pediatric Age Classifications Age-Appropriate Communication Infant/Toddler Measurements Height Weight Circumferences Pediatric Vital Signs Pediatric Development Motor Development Sensory Development Language Development Screenings Visual Auditory
Vaccinations Schedules Controversies Pediatric Injections Blood Screenings of the Newborn Circumcision Adolescent Care Height/Weight Puberty Sports and Athletics Behavioral and Mental Health Issues Depression Eating Disorders Abuse Suicide
19 Essential Terms adolescent anorexia nervosa bulimia nervosa chest circumference child circumcision familial stature head circumference immunizations infant language development macrocephaly microcephaly milestones motor development neonate newborn pediatric pediatrician percentiles phenylketonuria (PKU) puberty continues
E VA L U AT I O N A N D C A R E OF T H E P E D I AT R I C PAT I E N T
KEY COMPETENCIES
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CAAHEP
ABHES
Obtain a Height/Length and Weight on an Infant
III.C.3.b.4.b
VI.A.1.a.4.d
Obtain a Rectal, Aural, and Temporal Temperature on an Infant
III.C.3.b.4.b
VI.A.1.a.4.d
Perform a PKU on a Newborn Patient
III.C.3.b.2.b
VI.A.1.a.4.t
Perform a Pediatric Injection
III.C.3.b.4.g
VI.A.1.a.4.m
reflexes secondary sex characteristics sensory development sudden infant death syndrome (SIDS) toddler vaccinations
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Developmental Objectives After completing this chapter, you should be able to: 1. Correctly spell and define the essential terms. 2. Discuss the different age groups of patients within the practice of pediatrics. 3. Compare and contrast the different methods used when communicating with toddlers, adolescents, and parents. 4. Explain the need for precise documentation when recording height, weight, and circumference measurements. 5. Explain the normal pulse and respiratory rates for all age groups within the pediatric population. 6. List and describe seven types of blood screening tests for newborns. 7. Discuss the development of motor, sensory, and language milestones throughout the growth of the pediatric patient. 8. List and explain six common reflexes tested in the newborn. 9. Explain the methods used to determine if a child is hearing impaired. 10. List the childhood immunization guidelines and the ages at which each immunization is administered. 11. Debate controversies over childhood vaccinations. 12. Describe the different signs and changes during puberty, including secondary sex characteristics. 13. Provide patient education guidelines regarding baby safety and SIDS. 14. Discuss social issues that are affecting our youth’s health of today.
Introduction A pediatric practice presents special challenges in education due to the diversity of the patient population. The office setting might include any patient from a newborn to a young adult. In addition, there are often various caregivers involved in the patient’s care, which can create multiple levels of health and education needs. The medical assistant must be knowledgeable in all areas of pediatric wellness and must also be able to deal with the unique health challenges presented by this patient population.
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Character traits necessary to work in pediatrics include patience, honesty, and a love for children. Communication skills and the needs of the patient will often fluctuate at each unique developmental level. As the pediatric patient ages, ethical issues along with degrees of confidentiality become increasingly relevant. Social issues and concerns become a growing part of the pediatric patient’s development; therefore, it is important for all health care workers to be current in societal issues, pressures, and expectations. Apprehension and anxiety are often associated with areas of growth and development, as children unfortunately do not come with an instructional manual. Patient and family empathy must be developed. Educational support may be a large portion of the medical assistant’s role in the pediatric practice.
AGE-APPROPRIATE COMMUNICATION Age- and education-appropriate communication is important in developing a relationship with the patient and the patient’s family; especially in the field of pediatrics. Figure 19-1 illustrates the differences in the way the medical assistant communicates with the patient and the way she communicates with the patient’s mother. Speaking down to or over the head of an individual often creates barriers that hinder high standards of
FIGURE 19-1 (a) The medical assistant communicates with the toddler by getting down to his level and allowing him to examine the equipment. (b) The medical assistant adopts a more professional demeanor when communicating with the patient’s mother.
PEDIATRIC AGE CLASSIFICATIONS When thinking of the patients of a pediatrician, you might envision small babies in diapers. However, this is only a portion of the pediatric population. Many practices consider pediatrics to cover care from newborn through 18 years of age. The classification terms used for the various age ranges are as follows: ❖ Newborn: Usually refers to the initial period following birth ❖ Neonate: The first month of life ❖ Infant: The first year of life ❖ Toddler: Begins late in the first year of life and continues into the preschool years ❖ Child: Often correlates with school attendance and can be broken down into early childhood and middle childhood ❖ Adolescent or teenager: Related to the onset of puberty (age at which reproduction is possible) and development of secondary sex characteristics Some pediatricians may also address care of the unborn. Others provide continued health care over the age of 18, if special needs are identified. Some practices may define the levels of age based on school age, using terminology such as preschool development and school-aged development. Still other groups might classify patients into categories like infancy, early childhood, middle childhood, and adolescence. An understanding of these terms and how they may coexist is important in communication, patient education, and documentation.
(a)
(b)
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care, which may decrease patient compliance. Remember when conversing with a parent or adult caregiver of a young child that it is important to speak to the adult’s level of understanding. Remain professional and use correct but understandable terminology. Address parents by name and not “mommy” or “daddy.” The medical assistant must remember that he is no longer speaking to the infant or young child. Communication with small children often involves nonverbal interactions. Language may not yet be developed; therefore, expressions and motions must be considered. Often spoken language from the caregiver will conflict with the nonverbal communication from the infant. The health care worker must be aware of these possible contradictions. Squeals may be interpreted as pain or pleasure. A single word or sound may have multiple meanings. Caregivers are often the only interpreters available. Remember to communicate with both resources. When speaking with older children or adolescents, a communication barrier may exist. Current terms and expressions might be used by the patient that the medical assistant finds unfamiliar. Never assume a meaning or an intention. Always attempt to clarify what the patient is communicating. Consider that the patient may be attempting to test your reaction to words and phrases. Do you show disapproval, embarrassment, or acceptance? Communication, if appropriate, can be a major tool for successful evaluations and examinations. It can assist in the provision of quality health care while increasing patient and parent compliance.
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CR ITI C A L TH I N K I N G C H AL LEN G E While gathering patient history information, Ben, a 16-year-old patient, begins to use profanities that make you feel uncomfortable. He is watching you intently, while smirking. He also explains that his mom hates it when he uses “cuss” words, but that she is mean and just doesn’t understand. 1. How should you respond to Ben? 2. What are Ben’s intentions? 3. Should you say something to the provider or to Ben’s parents?
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INFANT/TODDLER MEASUREMENTS Infants and toddlers proceed through a rapid period of growth and change. Accurate and consistent measurements are necessary to evaluate normal and abnormal growth patterns. Trends are often tracked to identify any potential health care problems. Early detection is the key to prompt intervention. The medical assistant must be proficient in obtaining these measurements for evaluation. Sometimes, the behavior of young infants and toddlers can be unpredictable. For this reason, the medical assistant must be creative and flexible. Encourage parental assistance instead of interference while being tolerant and empathetic.
Height Height and weight measurements in the young child can be a clear indicator of potential health problems. The medical assistant must be proficient in obtaining these measurements for all levels of pediatric patients. Accuracy is essential, especially during the beginning years of growth. Members of the pediatric team must perform procedures similarly to ensure consistency and accuracy. Indicators of questionable health may be determined based not only on initial size, but on growth patterns or trends. Accurate documentation on approved records and charts is necessary to enable the health provider to assess growth patterns. The National Center for Health Statistics provides charts for height, weight, and head circumference. Figure 19-2 illustrates various growth charts, based on gender and age. These charts use percentiles, which compare the child’s measurements with an average range of growth for children in the United States. Many factors might come into play when assessing the measurement,
TOOL BOX
FI E L D S M A R T S If a child is in the 10th percentile for the child’s height, it means that based on averages, the child is shorter than 90% of other children in the same age range. If a child is in the 90th percentile for the child’s height, it means that based on averages, only 10% of children in the same age range are taller than the patient being measured.
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CHAPTER 19
Birth to 36 months: Girls Length-for-age and Weight-for-age percentiles Birth cm
L E N G T H
3
6
9
12
in 41 40 100 39 38 95 37 36 90 35 34 85 33 32 80 31 30 75 29 28 70 27 26 65 25 24 60 23 22 55 21 20 50 19 18 45 17 16 40 15
16
18
21
RECORD #
24
27
30
33
Birth cm
36 cm
AGE (MONTHS) 95 90
100
75
95
50 25
90
10 5
17
95 90
16
in 41 40 39 38 37 36 35
L E N G T H
38 L E N G T H
36 34
15
75
32 14 30
50
13 25
12
10
28 26
5
AGE (MONTHS)
7 12
14 W E I G H T
15
Birth to 36 months: Boys Length-for-age and Weight-for-age percentiles
NAME
15
18
Mother’s Stature Father’s Stature Date Age Birth
6 12 5 10
21
Weight
24
27
30
Gestational Age: Weeks Length Head Circ.
33
36
11
24
10
22
9
20
8
18
kg
16 lb
W E I G H T
W E I G H T
Comment
3
6
2 to 20 years: Girls Stature-for-age and Weight-for-age percentiles Mother’s Stature Date
Father’s Stature Age
Weight
Stature
BMI*
RECORD #
12 13 14 15 16 17 18 19 20 cm AGE (YEARS)
180 95 90
175 170
75
62 60 58 56 S T A T U R E
54 52 50 48 46 44 42 40 38
4
5
6
7
8
9
10 11
160
50 25
155
10 5
150
165 160 155 150
in 76
72 70 68 66
36 cm 100 95
25 10 5
90
95
17
90
16
in 41 40 39 38 37 36 35
38 36
15 32
50
14
25
13
30 28
10
12
5
AGE (MONTHS)
15
18
Mother’s Stature Father’s Stature Date Age Birth
6 5 10
21
Weight
24
27
30
Gestational Age: Weeks Length Head Circ.
33
36
26
11
24
10
22
9
20
8
18
kg
16 lb
4 8 3 2 kg Birth
3
6
9
S T A T U R E
120
85 95
115
80 90
75
75
50
Stature
BMI*
25
in
S T A T U R E
60 58 56 54 52 50
190
48
180
46
170
44
160
42
70
105
Weight
50
95 210 90 200
125
Age
RECORD #
12 13 14 15 16 17 18 19 20 cm AGE (YEARS)
75
62
60
100 220
130
Father’s Stature
NAME
95 90
62
105 230
150 W 65 140 E I 60 130 G
40 38
cm
3
4
5
6
7
8
9
10 11
10 5
190 185 180 175 170 165
160
160
155
155
150
150
in 76 74 72 70 68 66
62 60
145 140
105 230 100 220
135 130
95
125
90
120
95 210 90 200 85
115
75
80 75
110 105
50
100
25
95
10 5
190 180 170 160
70
150 W 65 140 E I 60 130 G
50 110
85
50 110
45 100 40 90
32
80
30
30
45 100 40 90
80
80
80
35
35
30
30
25
25
20
20
15
15
10 kg
10 AGE (YEARS) kg 10 11 12 13 14 15 16 17 18 19 20
32
70 60 50 40 30 lb
55 120 25 10 5
80
35
35
30
30
25
25
20
20
15
15
10 kg
10 AGE (YEARS) kg 10 11 12 13 14 15 16 17 18 19 20
2
3
4
5
6
7
8
9
Published May 30, 2000 (modified 11/21/00). SOURCE: Developed by the National Center for Health Statistics in collaboration with the National Center for Chronic Disease Prevention and Health Promotion (2000). http://www.cdc.gov/growthcharts
70 60 50 40 30 lb
H T
W E I G H T
70 60 50 40 30 lb
2
3
4
5
6
7
8
9
55 120
80 70 60 50 40 30 lb
Published May 30, 2000 (modified 11/21/00). SOURCE: Developed by the National Center for Health Statistics in collaboration with the National Center for Chronic Disease Prevention and Health Promotion (2000). http://www.cdc.gov/growthcharts
FIGURE 19-2 Height and weight growth charts for girls, birth to 36 months; boys, birth to 36 months; girls, 2 to 20 years; and boys, 2 to 20 years
S T A T U R E
64
90
90 85
W E I G H T
Comment
34
34
L E N G T H
34
75
Date
64
135
95
33
75
74
140
100
30
50
Mother’s Stature
145
110
27
36
36
W E I G H T
3
RECORD #
24
95 90
2 to 20 years: Boys Stature-for-age and Weight-for-age percentiles
NAME
185
cm
21
Published May 30, 2000 (modified 4/20/01). SOURCE: Developed by the National Center for Health Statistics in collaboration with the National Center for Chronic Disease Prevention and Health Promotion (2000). http://www.cdc.gov/growthcharts
190
in
18
AGE (MONTHS)
12
9
Published May 30, 2000 (modified 4/20/01). SOURCE: Developed by the National Center for Health Statistics in collaboration with the National Center for Chronic Disease Prevention and Health Promotion (2000). http://www.cdc.gov/growthcharts
15
12
lb
3
12
7
6
2 kg Birth
9
14
4 6
6
in 41 40 100 39 38 95 37 36 90 35 34 85 33 32 80 31 30 75 29 28 70 27 26 65 25 24 60 23 22 55 21 20 50 19 18 45 17 16 40 15
16
8
lb
3
NAME
H T
E VA L U AT I O N A N D C A R E OF T H E P E D I AT R I C PAT I E N T
including but not limited to, familial stature, gestational age at birth, and chronic disease. Refer to Figure 19-3 for an example of a growth chart that has been plotted. When measuring the height of an infant, it is often helpful to have a second set of hands, possibly those of the parent or guardian. Children younger than two years of age are measured in a supine position with the body fully extended. When using a caliper (an instrument used to measure the distance between two points), the top of the infant’s head is placed against the stationary head board of the caliper and the bottom of the foot is placed against the sliding foot board (Figure 19-4a). Refer to Procedure 19-1 for detailed instructions on obtaining a height measurement. Some clinics still use a tape measure to determine the length of an infant. The infant is placed in a supine position on the exam table with its legs fully extended. A tape measure is then placed along the side of the infant’s body (Figure 19-4b) and the measurement is recorded. A pencil mark is quickly made on the table paper at the top of the head and the bottom of the heel. The infant is then removed from the exam table
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(a)
FIGURE 19-3 A growth chart with patient information plotted and documented (b) Birth to 36 months: Boys Length-for-age and Weight-for-age percentiles Birth cm
L E N G T H
3
6
9
in 41 40 100 39 38 95 37 36 90 35 34 85 33 32 80 31 30 75 29 28 70 27 26 65 25 24 60 23 22 55 21 20 50 19 18 45 17 16 40 15
16
21
27
30
33
FIGURE 19-4 Recumbent length measurement using (a) a
36 cm 100
75
95
25 10 5
90
95
17
90
16
in 41 40 39 38 37 36 35
caliper and (b) a tape measure L E N G T H
38 36 34
75
15 32
50
14
25
13
30 28
10
12
5
AGE (MONTHS)
7 12
15
Mother’s Stature Father’s Stature Date Age 9-14-07 Birth
6
10
12-14-07 3 mo. 3-17-08 6 mo. 6-20-08 9 mo.
4 8
18
21
Weight
7¼ 12 15 18
3 2 kg Birth
RECORD #
24
50
5
lb
18
95 90
12
6
15
AGE (MONTHS)
14 W E I G H T
12
NAME
3
6
9
Published May 30, 2000 (modified 4/20/01). SOURCE: Developed by the National Center for Health Statistics in collaboration with the National Center for Chronic Disease Prevention and Health Promotion (2000). http://www.cdc.gov/growthcharts
24
27
30
33
Gestational Age: Weeks Length Head Circ.
18¨ 231 2 ¨ 26¨ 28¨
13 3 4¨ 151 2 ¨ 17¨ 13 3 4¨
36
24
10
22
9
20
8
18
kg
16 lb
Comment
AP AP AP AP
26
11
W E I G H T
and the distance between the two marks is measured to determine the height of the infant. Children that are older than two years of age can be measured while standing as seen in Figure 19-5. Be certain to remove the patient’s shoes and position the patient so that the patient’s heels, back, and head are in the same plane. This can be achieved by having the child stand flat against a wall. When obtaining the measurement, place a flat measurement tool on the patient’s head, at a 90° angle to the wall. The same measurement can be obtained with the use of an upright physician’s scale.
Weight Weight measurements provide another means for evaluating the pediatric patient’s growth and development. As with height, accurate measurement and documentation on an approved growth chart are important skills for the medical assistant to possess. Young infants are
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C R I T I C A L T H I N K I NG CHALLENGE Math is an important tool in any profession or walk of life. Accuracy in mathematical calculations is essential for the medical assistant when evaluating vital statistics that determine the level of growth and development. If an infant weighs 11 lb. 4 oz. with a diaper and small t-shirt on, it is important to understand how to calculate the true weight. Remove the diaper and shirt and weigh them on the same scale used to weigh the infant. Subtract the weight of the diaper and shirt for an accurate assessment. 1. If these articles weigh 6 oz., what would the infant’s weight be?
FIGURE 19-5 Children who are able to stand can be measured on an upright scale.
weighed directly on an infant scale (Figure 19-6). Ideally, they should be weighed naked or only in a diaper. Remember, any paper, diaper, or clothing also has mass; therefore, these items need to be weighed individually and subtracted from the total weight, if left on during the measurement. As children get older, screening techniques must be tailored to the comfort level of the child. Young children can often be weighed in their underwear, using a
FIGURE 19-6 One type of infant scale
standing scale. As they move into school age, a gown can be worn for the most comfortable and accurate evaluation. The weights of the gowns and underwear do not need to be determined for the older child because a fluctuation of ounces in these children would not be nearly as significant as they would be for an infant. The use of consistent equipment is more important.
Circumferences Another source of health evaluation is the measurement of head circumference and chest circumference. Accurate head circumferences trace the growth of the cranium and the brain. Abnormally large or small head sizes must be monitored closely. Macrocephaly, an abnormally large head, might indicate a pathologic disorder. This is often indicated if the head circumference measurement is larger than the 97th percentile. Again, familial or genetic trends also need to be considered before jumping to conclusions. Microcephaly, an abnormally small head, may also indicate a pathologic condition, such as a chromosomal disorder. When measuring the head circumference, it is important to consistently measure the same area of the head. Place the tape measure just above the eyebrows making sure that it fits snuggly and lies over the occipital protuberance and the supraorbital prominence (Figure 19-7). The circumference can be documented in either inches or centimeters according to office protocol. The chest circumference may or may not be ordered. It is often difficult to have consistent measurements due to various locations being measured. This mea-
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FI E L D S M A R T S A diagnosis of hypertension in the young child must be closely evaluated and may indicate renal disease or a disorder with the aorta.
Pediatric Vital Signs
FIGURE 19-7 The correct area for measuring head circumference
surement is an additional calculation that is used to identify low birth weights in preterm babies and may also be used when there is a suspicion of lung or heart disease. Another circumference that may be studied is that of the abdomen. This calculation may be ordered if the provider suspects there is a problem with one of the abdominal organs or abnormal swelling of the abdomen. If the health care provider requests either of these measurements, identify body landmarks such as nipples (for chest measurement) or umbilicus (for abdominal measurement) when documenting results. This will increase the possibility of evaluating growth trends.
Obtaining vital signs on the pediatric patient may be a bit challenging at times. Blood pressures are usually not obtained until the age of two. The size of the blood pressure cuff must be proportionate to the size of the patient. Cuffs come in various sizes to match the stages of child development. A child cuff is normally used on smaller children; however, a larger child may require the use of an adult cuff, just as a petite adult might require the use of a pediatric cuff. Size is important in the accuracy of blood pressure measurement. New or unfamiliar equipment is often traumatic for a young child. Many pediatric offices purchase equipment that is appealing to children. Pediatric cuffs are supplied in a variety of different colors and with different characters and scenes on the outside of the cuff (Figure 19-8). Allow the child to safely touch and test the sphygmomanometer and stethoscope (Figure 19-9). Demonstration of the procedure on the parent or older sibling often helps relieve anxiety. Another comforting method is to allow the young child to perform the procedure on a doll or stuffed animal. Of course, this should always be supervised for safety. Role playing and games often make evaluation tests more tolerable, even for the medical assistant.
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E M R A P P L I C AT I O N Many EMR software programs include graphing features. To graph growth percentiles on an electronic growth chart, you just click on the appropriate tab and enter the measurements within the requested field; the computer automatically graphs the measurements onto the electronic growth chart. Electronic results are usually more accurate because you don’t have to rely on the naked eye to trace where the horizontal line matches up with the vertical line.
FIGURE 19-8 A brightly colored pediatric blood pressure cuff
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Brachial artery
Femoral artery
FIGURE 19-10 The pulse is taken in the brachial or femoral artery in an infant. FIGURE 19-9 The child listens to the medical assistant’s heart before she listens to his heart.
The pulse in the young child varies with age and growth. What seems rapid for a school aged child may be absolutely normal for the infant. Most average pulse rates refer to a resting pulse. The young infant or toddler may be very active, thereby increasing the pulse rate. The primary locations for measuring pulse in infants and young children are different than the locations used for measuring pulse in the adult. The radial artery is normally used to check pulse rate on older children and adults but the radial artery is not very prominent in infants and small children. The femoral or brachial arteries (Figure 19-10) are the arteries of choice for pulse rate in infants and young children. Another method for obtaining the pulse will be through auscultation (listening to the heart with a stethoscope). As the child ages and develops, the radial pulse becomes easier to obtain. Respirations in the infant and toddler can be measured along with the pulse. The rates will vary, depending on the level of activity or illness. Remember that a fever can elevate the respiratory and pulse rate. Refer to Table 19-1 for normal ranges of pulse and respiratory rates in pediatrics.
Obtaining an accurate body temperature is another skill that is essential for the medical assistant. Fevers are quite common in pediatric patients and often their fevers have higher peaks than fevers that are typically seen in adult patients. There are several methods that can be used to obtain a body temperature reading on a pediatric patient. In children and adolescents, auditory canal or aural readings are quick and relatively comfortable, which encourages patient compliance. Infants younger than two months of age are best evaluated with a temporal thermometer (refer to Chapter 11 for further discussion of temporal temperatures). If it is necessary to obtain a rectal temperature reading, it must be completed with caution, as it is moderately invasive. Refer to Procedure 19-2 for detailed instruction and rationale for obtaining body temperature readings in the pediatric patient. Pediatric measurements and vital signs are key evaluation tools for identification of any potential disorders.
PEDIATRIC DEVELOPMENT In addition to physical measurements used to evaluate pediatric progress, other areas of growth and
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TABLE 19-1 Average Heart Rates and Respiratory Rates in Pediatrics
AGE
AVERAGE HEART RATE BEATS AVERAGE PER MINUTE RESPIRATORY (BPM) RATE
Birth
140 BPM
30–60/min
0–6 months
130 BPM
20–40/min
6–12 months
115 BPM
20–40/min
12–24 months
110 BPM
20–40/min
2–6 years
100 BPM
20–30/min
6–10 years
95 BPM
15–25/min
10–14 years
85 BPM
15–25/min
14 years–adult
80 BPM
16–20/min
development include motor, sensory, and language development. Different ages have normal milestones, which indicate acceptable growth and development patterns. These milestones are most often used during the first two years of life and are meant to provide assistance with knowing the average timeline when these milestones occur. Keep in mind, however, that many infants and toddlers reach these milestones earlier or later than other children and are completely normal.
Motor Development The category that includes motor skills provides visible and exciting changes in the growth of the child. These are usually celebrated developments that are documented by parents and compared for generations. Motor development allows the child to develop more independence, which encourages sensory, cognitive, and language growth. Motor development usually includes three areas of growth: reflexes, gross motor, and fine motor skills. Reflexes refer to automatic responses to any stimulation. Common reflexes are listed below: ❖ Breathing reflex ❖ Sucking reflex ❖ Rooting reflex: When brushing the cheek, the infant turns toward it to suck ❖ Swimming reflex: When held horizontal, begins stretching and swimming motion ❖ Grasping reflex: Grips when palms are touched ❖ Moro reflex: Startles to loud banging and other environmental stimuli
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These reflexes are seen in the normal newborn and lead to voluntary responses or gross motor skills. Gross motor skills include motions such as rolling, scooting, crawling, and walking. Just as gross motor skills involve the development of large muscles groups, fine motor skills develop utilizing smaller movements. These include motions such as touching, grabbing, poking, pulling, and pinching. Gross and fine motor skills often develop during the same time periods, usually complementing each other’s growth. Refer to Table 19-2 for a general timetable for normal gross and fine motor development.
Sensory Development During motor development, sensory, perceptual, and cognitive growth is also progressing. Vision and hearing are improving along with depth perception and motion assessment. All of these sensory developments continue to promote further motor development. Any single area that exhibits impairments will affect the growth in other areas of development. For example, if vision is impaired, some fine motor skills may be slow to develop and a lack of depth perception can inhibit gross motor skills. Visual development involves increasing distances in sight as the brain matures. This maturation allows for better focus and increased tracking of objects as the child grows. Color perception also develops as the child grows. Hearing improves in normal sensory development as the child matures. Varying pitches and frequencies can be differentiated. Notice how babies listen to cooing or baby talk from others. A positive response occurs with higher pitched baby jargon. As they grow
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C R I T I C A L T H I N K I NG CHALLENGE A mother comes in and is upset because she read an article in a mother’s magazine that stated that the normal age for an infant to sit up without support is somewhere between five and six months. The mother is concerned because her son is seven months old and still needs assistance when sitting up. 1. What can you say to the mother to help reduce her anxiety? 2. Should you share the mother’s concern with the provider?
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TABLE 19-2 Normal Gross and Fine Motor Developmental Milestones PATIENT’S AGE (MONTHS)
GROSS MOTOR DEVELOPMENT
Newborn to 1 month
FINE MOTOR DEVELOPMENT The hands are in fists and the hands and legs are pulled inward and upward to the body
2
Lifts the head when on stomach
3
Rolls over Sits when propped
Touches an object
5–6
Sits without support
Grabs an object and holds
6
Stands with support
Transfers an object between hands
9
Walks while holding on
Attempts to catch thrown objects
9–10
Stands alone
Uses thumb with forefinger to grasp
12
Walks alone
14
Walks backward
17
Walks on stairs with help
20
Kicks a ball
and develop, deeper noises also attract interest. The ability to locate sounds also occurs as the child develops. Initially, infants have a difficult time identifying the direction of a noise or voice. As they develop, they are better able to locate the noise.
Language Development From infancy forward, the child begins with noises that elicit a response. This progresses to words, phrases, and finally sentences. Normal language milestones help identify intellectual development. The timing may differ due to educational and environment circumstances, but it appears that universal trends occur in language development. Refer to Table 19-3 for normal developmental trends in language.
Prior to early school age, visual milestones are evaluated. These include blinking, fixation on objects, coordination of eye movements, and reaching for objects. The medical assistant can help the health provider evaluate these milestones. Shaking eye movements and wandering eyes might also be observed and documented. As the child matures, more standard eye exams can be utilized to test visual acuity. Because pediatric visual screenings are performed the same as those performed on an adult, refer back to Procedure 13-1, which lists the steps involved. The only difference in the procedure will be the type of chart used. Remember the educational level as well as the reading ability of the patient during the testing. This may alter the chart that is used and the directions given.
SCREENINGS
Auditory
Sight and hearing screenings are also conducted at different age intervals throughout a child’s development. Periodic screenings can alert the provider to potential problems that can be treated or corrected.
Screening for hearing in the newborn and infant begins immediately at birth. Lack of hearing is often misinterpreted as intellectual delay. Communication with parents or caregivers may enlighten the health care provider to signs of a hearing deficit. Clues include responses to loud noises, facial expressions, and turning the head toward noises. As the child matures, more formal testing of hearing can be completed. This can be done by using simple
Visual Pediatric visual screenings and examinations begin in infancy. Charts used to conduct pediatric visual screenings are discussed in Chapter 13.
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TABLE 19-3 Language Development in the Pediatric Patient PATIENT’S AGE (MONTHS)
LANGUAGE DEVELOPMENT TRENDS
Newborn
Reflexive: cries, expressions
2
Coos, cries, laughs
3–6
Squeals, trills, uses vowel sounds
6–10
Babbles, repeats sounds
10–12
Understands simple words and commands
13–18
Speaks first true words and number of words begins to increase rapidly
20
Starts putting words together into very short sentences
24
Puts longer sentences together
Disclaimer: The above ages are merely guidelines and not exact. Because of the differences from one child to the next, one may perform tasks at a certain age while another will not. This does not necessarily indicate a cause for alarm.
commands or sound identification. Audiometric equipment can be used. Speech delays or impairments may indicate hearing deficits. Remember to always look at the overall picture.
VACCINATIONS In an effort to prevent the spread of identified communicable diseases, a series of vaccinations or immunizations has been recommended by the World
TOOL BOX
P ATIEN T TU T OR Discuss with the parent or guardian of a young infant possible signs of a hearing deficit. When the dog barks, does the infant startle or cry? When his name is called, does the infant turn toward the sound? Does the baby make cooing or babbling noises? The answers may provide clues indicating hearing problems. Be sensitive when discussing these with the parents. This is also a good time to stress the importance of never probing inside the ear of an infant or child. Remember: “Nothing smaller than the size of the patient’s elbow should go in the ear.”
Health Organization. Infectious diseases have, in the past, led to worldwide epidemics, often increasing pediatric health complications leading to death. Studies show that the infant fatality rate from disease is decreasing due to the use of vaccinations, according to UNICEF studies. These include smallpox, whooping cough, polio, diphtheria, tetanus, HIB, hepatitis B, measles, mumps, and rubella.
Schedules Pediatric schedules include the suggested age of the patient along with the specific vaccinations for the country in which the patient lives. The Centers for Disease Control and Prevention (CDC) provides guidelines for immunizations. The medical assistant is often responsible for administration of the vaccination, either orally, topically, or by injection. In addition, the medical assistant will be involved in providing the necessary patient education related to the risks and side effects of each individual vaccine. For a detailed description of the childhood immunization schedule along with concise descriptions of each vaccine, refer to Figure 19-11.
Controversies Even as the infant mortality rate has improved due to the increased provision of vaccinations throughout the world, health concerns and patient rights topics have created additional controversy. Risks versus benefits associated with vaccines need to be understood by the medical assistant along with the patient. In the United States, immunizations are voluntary. Accord-
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FIGURE 19-11 The recommended immunization schedule for infants to adolescents
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ing to a CDC study conducted in 2003, approximately 74% of children were delayed for one or more vaccinations during the first 24 months of life. Parents may accept the risk and responsibility for not obtaining the vaccines for their children. There may also be concerns related to religious beliefs. Economic levels and education are also key components in this health care quandary. Although the primary health provider is responsible for discussing the recommendations and controversies with the patient and family, the medical assistant should be aware of these statistics and associated issues. The safety of the patient, along with the community, needs to be considered. Refer parents to appropriate Web sites to enable them to make educated decisions regarding their children. The World Health Organization’s Web site, www.WHO.int, discusses suggested schedules along with vaccine safety. The Global Advisory Committee in Vaccine Safety (GACVS) is also a useful resource. When discussing these choices, do not belittle personal preferences such as religious beliefs. The CDC provides vaccine information statements that are given to the patient and caregiver prior to vaccination. An educated choice by the parents is the desired outcome along with respecting patient rights. Do not attempt to force the patient into your arena of beliefs. Documentation of the vaccine must be thorough. The type of vaccine given, the lot number, the method of administration, and location of injection is placed in
P A T I E N T P E R S P E CT IV E There is so much contradictory information regarding childhood immunizations on the Internet. One site states that you should have your child immunized yet another site describes why you shouldn’t have your child immunized or the benefits of waiting until the child is a little older before becoming immunized. No wonder I am so confused! Please avoid getting upset with me when I ask questions regarding safety factors and possible side effects of the immunizations. I just want to make certain that I am doing the right thing. Supply me with names of Web sites that will reinforce the physician’s position for having the immunizations administered at the times they are suggested. Perhaps you could alert the physician of my concerns so that the physician can make me feel more at ease.
the patient record or immunization log (Figure 19-12). Also recorded is the vaccine information that is provided to the guardian, including the date and any concerns expressed.
DOUGLASVILLE MEDICINE ASSOCIATES 5076 BRAND BLVD DOUGLASVILLE, NY 01234 (123) 456-7890 PATIENT IMMUNIZATION LOG
DOB: 05/05/08
Date
Time
Vaccine Name and #
Route
07/05/08
10:00 a.m. 10:01 a.m.
DTaP # 1
IM
0.5 ml
HIB # 1
IM
0.5 ml
10:02 a.m. 10:03 a.m.
IPV # 1
IM
0.5 ml
PCV # 1
IM
0.5 ml
07/05/08 07/05/08 07/05/08
Amt Location Clinician R. Thigh (Upper) R. Thigh (Lower) L. Thigh (Upper) L. Thigh (Lower)
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FIGURE 19-12 A patient immunization record
Patient’s Name: Bethany Johnson
❖
Manuf. Name
Lot #
Dr. Brown
SPS
125621A
Dr. Brown
SPS
653214D
Dr. Brown
SPS
Dr. Brown
SPS
VIS Form Date
Initials of vaccinator
01/20/09
07/05/08
06/01/09
07/05/08
256845A 04/01/09
07/05/08
02/01/09
07/05/08
S. Smith, CMA (AAMA) S. Smith, CMA (AAMA) S. Smith, CMA (AAMA) S. Smith, CMA (AAMA)
111155D
Exp Date
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CR ITI C A L TH I N K I N G C H AL LEN G E Refer to the Patient Perspective tool box on the previous page. 1. Why might the parent share her anxiousness with you but not with the provider? 2. If you are working in an office that has wireless Internet and monitors in each room, what might you do to help ease the patient’s mind?
PEDIATRIC INJECTIONS The medical assistant is often responsible for performing pediatric injections. Proper skills need to be devel-
oped for the comfort and safety of the patient. Undue trauma, either physical or emotional, needs to be minimized. Assistance from the parent or caregiver may be necessary. Most pediatric injections are administered intramuscularly. The location of an intramuscular injection is usually the vastus lateralis muscle of the thigh. The type of medication or vaccine administered will dictate the location of the injection. The age and size of the patient also helps to determine the most effective injection site. Table 19-4 compares the various sites. The size of the needle is dependent on the medication injected along with the size of the patient. For intramuscular (IM) injections, the length should be 58 ⁄ to 1 inch, with the gauge range from 23 to 25 gauge. The amount of medication injected ranges from 0.5 mL in infants to 0.5 to 2 mL in children. An important part of the medical assistant’s responsibility is to calm the patient both before and after the
TABLE 19-4 Intramuscular Injection Sites in the Pediatric Patient INJECTION SITE
INDICATION
AGE
TECHNIQUE
Deltoid
Smaller amount of medication given
Not typically used until the child is older. Provider preference will be the rule.
The deltoid is held taut. The needle is inserted into the muscle at a 90° angle. The needle size is dependent on the patient size. This area can be tender if used repeatedly.
Gluteal
Larger amount of medication, but only if the muscle is adequately developed
Over two years of age
Place the child on the stomach with feet turned inward. The muscle is held taut and the injection is given at a 90° angle. Caution must be used due to the location of the sciatic nerve. Poor development of the muscle is a contraindication. Excessive movement by the patient may create difficulties.
Vastus lateralis
Any amount of medication; used for “squirming” children because it is easier to contain the patient
Small infants and the young child
The infant is placed on the back, often in the lap of the caregiver. The parent can stabilize the patient. The muscle is held taut while also stabilizing the patient’s leg. The injection is given at a 90° angle.
F IELD SM A RTS There are mixed opinions on how to hold the skin when administering an IM injection to infants. Some sources say to pinch the skin while others say to pull the skin taut. If pinching the skin, a slightly longer needle may be needed to ensure that the medication is deposited in the muscle and not the subcutaneous tissue. Angles
injection. Children are often alarmed about receiving an injection and every effort should be made to calm their fears so they are not apprehensive about receiving injections in the future. The medical assistant can be instrumental in achieving this goal. As the child matures and can understand procedural explanations, honesty is important. Never promise the child, “This won’t hurt at all.” This will instill distrust for future injections, even to the point of hysteria. Provide an explanation of the minimal discomfort that might occur. Parent comfort may also be necessary. Parent involvement needs to be evaluated to ensure a positive encounter. Some parents may elicit a calming environment, while others may cause more turmoil. Once again the goal is to avoid future fears, making the provision of quality health care a realistic possibility. Refer to Procedure 19-4 for instructions on how to perform a pediatric injection. Chapter 8 has several tips for communicating with pediatric patients and provides helpful hints for performing invasive procedures on children.
BLOOD SCREENINGS OF THE NEWBORN A complete evaluation of the newborn involves analysis of the blood to identify any potential physiological diseases. Screening tests can be initiated in the hospital, but may occur up to seven days later. States have varying requirements as to what is included in the infant blood screenings. Capillary blood is collected from the infant’s heal (Procedure 19-3) and may be tested for diseases. The following test is performed on all infants: ❖ Phenylketonuria (PKU): PKU is a congenital familial disease. Patients with this disorder are
may also be varied. A 90º angle should be used when the baby has lots of fat over the area where the injection is being administered, whereas a 45º angle may be necessary in cases where the baby has little body fat. Office protocol should be followed when working in the industry.
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deficient in the enzyme phenylalanine hydroxylase. making them unable to metabolize or break down the amino acid phenylalanine. This causes increased levels of phenylalanine in the blood, which can cause mental retardation, seizures, and muscular difficulties. Since phenylalanine is present in milk, the test for PKU is attempted 24 hours after the ingestion of milk, either from the breast or formula. The evaluation will demonstrate whether or not phenylalaine has been metabolized. Most states require this blood test within the first several days of life. If not obtained, a urine test can be evaluated after six weeks of age. Prompt diagnosis is essential for a favorable prognosis so that a diet that restricts phenylalanine (often seen in meat and dairy products) can be quickly implemented. The following tests are only performed if symptoms are present or there is family history of the disease: ❖ Sickle cell anemia: This type of anemia is an inherited disorder with the highest incidence occurring in the African-American, native African, and Mediterranean populations. Red blood cells are sickleshaped rather than a normal circular shape. The RBCs also contain an abnormal type of hemoglobin know as hemoglobin S. Because of their sickle shape, the RBCs clump together, which reduces blood flow to essential areas of the body. Clot formation can also occur, causing a blockage in the blood vessels. This in turn causes inadequate amounts of oxygen to be delivered to the body, resulting in chronic anemia. Other symptoms include paleness, weakness, and extreme fatigue. ❖ IRT (immunoreactive trypsinogen): This is a marker for the possibility of cystic fibrosis. Positive indicators alert the provider to the need for more testing.
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❖ Hypothyroidism: Decreased function of the thyroid gland affects the metabolism of the infant. A thyroid panel assists the provider in making a diagnosis. ❖ Homocystinuria: This is a rare metabolic disorder characterized by an excess amount of the amino acid homocysteine. ❖ Ketonuria: The presence of ketone bodies (products of fat metabolism) in the urine. ❖ Galactosemia: This condition is characterized by the inability to metabolize galactose and is the result of an absence of one of two enzymes that are needed to convert galactose into glucose.
CIRCUMCISION Circumcision, or removal of foreskin of the penis, is commonly performed on newborn infants while they are still in the hospital. However, due to unforeseen circumstances, the procedure is sometimes performed in the office. A health consideration for having the procedure is that it reduces the risks of penile infection due to bacteria buildup under the foreskin. Other considerations for having the procedure include appearance and religion. There is new evidence that favors circumcision. The incidence of cervical cancer appears to be lower in females with male partners that are circumcised. Conversely, pain and necessity are also considerations for not having the procedure. Past generations have argued there is no pain, but this is difficult to evaluate in the newborn. In general, this is a choice
made by the parent after delivery. Some religions prohibit circumcision. The medical assistant must remain unbiased, empathetic, and supportive during this controversial decision process.
ADOLESCENT CARE The period of adolescence begins around the time of puberty. This is when the secondary sex characteristics become more obvious. This is also the time frame when youths attempt to display more independence. Exploration into various avenues, such as drugs, tobacco, alcohol, and other substances that alter the mind, can occur. Body images are questioned. The challenges of daily life expand. Communication during this period of development is crucial. The patient may wish to discuss issues with health care providers in confidentiality. Since the patient is a minor, this often poses ethical and legal concerns. Adolescents may also attempt to challenge the authority of health providers by trying to intimidate or embarrass the professional. It is important to remain nonjudgmental, while exhibiting empathy and compassion in a professional manner. Demonstrating feelings of disgust, fear, or shame will hinder compliance needed for a high standard of care.
Height/Weight Height and weight can present significant concerns for the adolescent. Obesity is prevalent in today’s American society. Various forms of media attempt to
Sudden infant death syndrome (SIDS) is the second leading cause of death of infants in the United States. It is often related to nighttime apnea (stoppage of breathing for approximately 20 seconds). SIDS is the death of an infant, usually under one year of age, with no known cause. If a cause is identified, it is not SIDS. Apnea combined with bradycardia (slow pulse) is a precursor for SIDS, which usually occurs from the second to the fourth month, but not exclusively. Pathological changes may be related to the respiratory, cardiovascular, or nervous system. You can alleviate apprehension
in parents by thorough examination, education, and emotional support. Some preventive measures can be implemented. Limiting smoking during pregnancy, reducing low birth rates, and placing sleeping infants on their backs may help reduce the number of SIDS cases. Also, do not allow excessive smoke around the baby. This increases upper respiratory infections. Respiration rates are also related to the condition. If a family sadly loses a child to SIDS, reinforce that there is no known cause of SIDS. It cannot be predicted and fault cannot be placed on the caregiver if an infant dies of SIDS.
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PAT I E N T T U T O R
PAT I E N T T U T O R Childhood obesity is becoming a huge problem in today’s society. Many factors contribute to this problem, including genetics. Most families are dual employed leaving children to prepare their own nutritionally challenged meals. Some parents are so fatigued after a long day that fast food is often the meal of choice. Many households have televisions and computers that have
set standards that are not necessarily realistic, healthy, or achievable. Always use sensitivity when discussing “normal” heights and weights. Height and weight chart figures vary, depending upon the company and the purpose for which it was developed. They do not often account for growth periods, muscle mass, levels of exercise, and health conditions such as diabetes and should only be used as a guideline, not as exact scientific information. A more recently used tool for evaluation is the body mass index (BMI). This method incorporates body fat into standardized height and weight measurements. The relationship of body fat to size is a valuable assessment for health. Further discussion of BMI can be found in Chapter 11.
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CR ITI C A L TH I N K I N G C H AL LEN G E Scott, a 15-year-old patient, arrives in the office with his father. His father wants to be involved in the examination because he suspects that Scott might be sexually active. Scott is willing to talk to the provider and you, but only if his father leaves the room. When alone, he asks that his father not be told anything. He proceeds to discuss his sexual preferences, maybe a little too graphically for you. 1. How should you handle this situation? 2. Should you inform his father about the information you received? 3. Is this a legal or an ethical situation?
become the primary focus instead of some type of physical activity. Obesity leads to many disorders as the child grows, including diabetes, heart disease, orthopedic injuries, and respiratory disorders. Proper nutrition and exercise need to be addressed early in a child’s development to prevent obesity from occurring.
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Puberty As the pediatric patient grows and develops, sexual changes begin to develop and reproduction becomes a possibility. With girls, breast buds become apparent, pubic hair begins to grow, and the first menstrual cycle may occur. There is often a height and weight growth spurt. During this time, estrogen and progesterone hormones are increasing. All of these changes combined can easily create emotional fluctuations. The exact age of this development may vary, but generally follows a standard pattern. Questions of sexuality and independence arise. Self image becomes very important. Boys will have an increase in the production of testosterone during puberty. Their testes, scrotum, and penis will enlarge, while pubic hair will begin growing. Adolescent boys may experience a height and weight growth spurt, but this may occur at a later time than girls of the same age. The widening of shoulders also becomes apparent. Facial hair and lowering of the voice may create embarrassment and discomfort regarding self image. Boys may also go through a brief period of time where their voice is similar to an adult female (such as their mother), which can be very embarassing to the adolescent. The onset of puberty varies between different cultures. Certain cultures and nations proceed through these changes at different rates. This might be attributed to health, sanitation, and nutrition. Certain medications may cause variances. As health care providers, it is important to remember that individuals differ in development. Normal is not necessarily synonymous with average. Therefore, if a patient does not fall into the average category, this should not be interpreted as abnormal. Secondary sex characteristics are the visual changes seen as girls and boys develop differently. Breasts, hips, and voice are examples. These are sexual
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P ATIEN T TU T OR
FI E L D S M A R T S
A patient with a concussion may exhibit some of the following signs:
Each year in the United States, there are approximately 24 sports-related deaths among high school and college athletes from sudden cardiac arrest. To date, only a few schools require EKG screening for their student athletes. Some feel that cardiac screenings should be mandatory before a student can participate in sports. Screenings could help to prevent some of these deaths by discovering undiagnosed congenital defects or conditions.
❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖
Headache Visual changes Dizziness Nausea Vomiting Drowsiness Restlessness Fatigue Irritability
If any of these signs are observed after a head injury, the patient should seek immediate medical attention.
features that are not necessarily related to reproduction. An adolescent male growing a beard may indicate puberty, but this is not directly related to reproduction.
Sports and Athletics High school creates a competitive environment, not only academically, but athletically. Examination of pediatric patients involved in athletic programs must include both physical and emotional components, and most schools are now requiring annual physicals prior to participation. Injuries are often a consequence of playing sports. Refer to the Patient Tutor tool box on this page for information on concussions and Chapter 35 for information on other types of injuries.
BEHAVIORAL AND MENTAL HEALTH ISSUES
from depression. A diagnosis of depression is often difficult because of the different developmental changes experienced throughout the pediatric time frame. The cues may be confusing to the parent. For example, irritability may be related to hormonal changes or to depression. Listening to the child might be the best indicator. The adolescent will often express depression before anyone else discovers it. Friends may be able to provide some information that will be helpful in diagnosing depression. In general, the signs that could indicate childhood depression are: ❖ Increased physical complaints that cannot be directly related to any syndrome or illness ❖ Decreased performance in school or activities ❖ Increased periods of crying or complaining ❖ Increased boredom ❖ Dangerous behavior ❖ Isolation from peers and family ❖ Substance abuse ❖ Wanting to run away ❖ Increased fear of failure ❖ Feelings of hopelessness
Depression
Identification of depression is important for prompt treatment. Many evaluation tests are available such as the Beck Depression Inventory (BDI). Evaluation of the family history is also important as depressive conditions can be inherited. Girls are also more likely to develop depression than boys, but depression in boys is more difficult to diagnose. Other areas to consider as risk factors include:
Often a hidden disorder, the diagnosis of depression may be overlooked, and yet, this may begin in the very young child. Temporary sadness must be differentiated
❖ Loss of family member ❖ Loss of pet ❖ Breakup of relationship
Some problems such as depression, eating disorders, abuse, and suicide are thought to be primarily adult issues, but they can also occur in the pediatric patient. The health care provider must be aware of the signs and symptoms in order to arrive at a diagnosis for these problems.
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❖ Confusion about sexual orientation ❖ Illness ❖ Abuse Depression must be identified as it can progress down dangerous avenues, which might include eating disorders or suicide. Be particularly aware of abuse, both physical and psychological, from family, friends, or schoolmates.
Eating Disorders Common eating disorders seen during the pediatric years are anorexia nervosa and bulimia nervosa. Primarily seen in the adolescent years, these conditions require both medical and psychological support. Self image is a major concern for youths. Peer pressure and media input often encourage appearances that are unobtainable with healthy eating patterns. Refer to Chapter 14 for a more thorough discussion on eating disorders.
Abuse Health care providers are required to report any suspected abuse on a pediatric patient. Determination of abuse might be through physical examination and through active listening skills. During the pediatric examination, the provider will observe for signs of bruising, lacerations, scarring, and tenderness. Remember, however, children have accidents and some bruising is normal. Medical assistants should listen for clues
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C R I T I C A L T H I N K I NG CHALLENGE When preparing to obtain a two-year-old’s height and weight, you notice some round scars on the back of the leg, the shoulder, and one of the hands. The scars resemble cigarette burns and you are concerned about child abuse. 1. How should you handle this situation?
during the patient screening phase that may indicate physical or emotional abuse, and discuss with the provider any concerns they may have. Keep in mind the safety for all involved including the patient, family, and health providers. It is not the responsibility of the medical assistant to confront any potential abuses.
Suicide An alarming statistic is that suicide is the third leading cause of death in 10- to 20-year-old patients. Because of this, all health care providers, including the medical assistant, must take any suicide threat seriously. It is a complete myth that anyone who talks about suicide will usually not complete the act.
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PROCEDURE 19-1 Obtain the Height/Length and Weight of an Infant Objective: To obtain accurate measurements of the height and weight of an infant and correctly plot them on a growth chart.
Equipment/Supplies: ❖ Exam table paper ❖ A measuring device/caliper ❖ Infant scale, balanced
❖ Patient record ❖ Length and weight percentiles flow sheet ❖ Pen
PROCEDURAL STEPS
RATIONALE
1. Wash your hands and assemble the equipment.
Handwashing is the principle method of preventing the spread of infection. Having all of the equipment ready prior to handling the infant ensures more efficient use of time with the child.
2. Identify the patient using two identifiers, and identify yourself. Ask the parent to remove the child’s clothing, except for the child’s diaper.
This allows for a more complete examination. The parent assisting will comfort the infant and allow you to measure the infant.
3. Place the infant face up on the paper on the exam table with the top of the infant’s head flush with the top measuring bar of the caliper.
In this position, eye contact can be made with the infant.
4. Stretch the infant’s legs to their full length and place the sole of the foot flush with the bottom measuring bar of the caliper. Use caution when extending the joints. Do not pull on the neck or legs. Be gentle. Have the parent support the head and neck, if needed.
Be prepared to work rapidly but accurately. Babies do not lie still for very long.
5. Document your results immediately on the patient record and the growth chart.
Immediately documenting the results prevents errors.
6. After completing measurement of length, place the infant on the infant scale, lined exam paper, or towel. The scale should be balanced to zero prior to the exam.
Paper or a towel provides a cleaner, warmer environment.
7. Have the parent comfort and support the infant. Make sure that the parent does not exert additional weight.
This will decrease squirming, which will make reading the scale easier.
8. Obtain a reading. Remove the infant from the scale. Remove the diaper from the infant. Place the diaper on the scale and weigh.
The weight of the diaper and paper alone will allow you to calculate the weight of the infant. Another option is to weigh the infant without a diaper.
9. Calculate the infant’s weight. Remember: total weight – diaper = infant weight.
Avoid math errors.
10. Document your results immediately on the patient record and growth chart.
Accurate documentation is the only method for tracking growth and development trends.
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DOCUMENTATION EXAMPLE:
7-02-XX 1130
Pt. here for five-month well baby exam. Length: 22", Weight: 19 lb. Parent assisted with measurements. Tara Smith, RMA
PROCEDURE 19-2 Obtain the Temperature of an Infant or Young Child Objective: To obtain an accurate body temperature reading on an infant by performing a rectal, aural, or temporal temperature.
Equipment and Supplies: ❖ Electronic rectal thermometer and probe cover, tympanic thermometer and probe cover, or temporal thermometer ❖ Lubricant ❖ Tissues
❖ Gloves ❖ Watch or clock ❖ Patient record
PROCEDURAL STEPS
RATIONALE
1. Wash your hands and assemble all the equipment. Put on gloves.
Handwashing is the principle method of preventing the spread of infection. Having all of the equipment ready prior to handling of the infant ensures more efficient use of time with the child.
2. Identify the patient using two identifiers, and identify yourself.
Performing any procedure on the wrong patient can cause problems for the patient and using an incorrect chart can cause administrative problems.
3. Explain the procedure. Have the parent remove the infant’s clothing.
This will be more comforting to the infant. This will also provide quality time for you to interact with the parent.
Rectal temperature: 4. Place the infant on the abdomen in your lap, or the infant may be placed in a supine position (Figure 19-13). 5. Apply a clean probe cover and lubricant to the rectal thermometer.
These positions provide the most comfort for the patient and the most control for the medical assistant. The probe cover protects the thermometer from contamination. The lubricant allows for easiest insertion into the rectum.
FIGURE 19-13 The proper positions for obtaining a rectal temperature
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PROCEDURAL STEPS 6. Gently insert the thermometer into the infant’s rectum approximately one inch. Hold it securely. Leave the thermometer in place until the signal that indicates the reading is complete.
RATIONALE Gentle insertion prevents damage to the rectal area. Holding the thermometer securely will prevent it from being drawn into the colon.
7. Remove the thermometer. Remove the sheath and discard it in the biohazard container. 8. Observe the reading, disinfect the probe with alcohol, and place the probe into its storage slot on the unit.
Proper storage of the probe will prevent damage.
9. Remove excess lubricant from the anal area of the infant. Discard the tissue appropriately. Aural temperature: 10. Place the probe cover on the thermometer. 11. Insert the thermometer gently into the ear canal and press the activation button. For best placement and most accurate results, pull gently down and backward on children under the age of three (Figure 19-14) and up and back on children three and over.
Covering the probe eliminates cross-contamination. Gently pulling the ear lobe down and back in children below the age of three and up and back in children over the age of three helps to properly position the canal for a more accurate reading.
FIGURE 19-14 Pull down and back on the ear canal before inserting the tympanic thermometer.
12. After the signal sounds indicating that the reading is complete, remove the thermometer and note the reading. 13. Discard the probe cover in the appropriate container. Temporal temperature: 14. Clean the thermometer with an alcohol swab and check to be sure the thermometer is in working order.
Cleaning the thermometer between patients helps to prevent crosscontamination.
15. Check the forehead for any moisture and begin with the probe at the midline of the forehead. Keeping the probe flush with the skin, press and hold the scan button and slowly glide the thermometer across the forehead to the location of the temporal artery (Figure 19-15).
Holding the probe flush with skin will ensure an accurate reading.
16. Remove gloves, if worn, and accurately record the information on the patient’s record indicating the method performed.
The method must always be recorded. Otherwise, it will be assumed it was by the oral method.
FIGURE 19-15 Glide the temporal thermometer across the infant’s forehead to the temporal artery.
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DOCUMENTATION EXAMPLES:
6-02-XX 0920
T- 102.4° (Rectal). Pt. tolerated procedure well. Shamika Thomas, CMA (AAMA)
5-7-XX 1000
T- 99.2 (Aural). Sara Moore, SMA
PROCEDURE 19-3 Perform a PKU on a Newborn Objective: To obtain a blood sample from a newborn and correctly apply the sample to the test card for evaluation of PKU.
Equipment/Supplies: ❖ ❖ ❖ ❖ ❖
❖ Sharps container ❖ Small adhesive bandage ❖ Patient record/pen
Antiseptic wipe Sterile gauze or 2x2 Lancet (sterile) Gloves Newborn Examination Test Card with envelope
RATIONALE
PROCEDURAL STEPS
Proper handwashing is the single most effective way to prevent the spread of contaminants. Having the equipment ready and the card completely filled out makes the procedure run smoothly. This is important when dealing with infants.
1. Wash your hands and assemble the equipment. Complete all required information in the patient section of the test card (Figure 19-16).
FIGURE 19-16 A PKU test card DO NOT WRITE IN SHADED AREAS - DO NOT WRITE ON OR NEAR BAR CODE
ALL INFORMATION MUST BE PRINTED
/
/
TIME:
(USE 24 HOUR TIME ONLY)
:
BABY’S NAME: (last, first) HOSPITAL PROVIDER NUMBER:
SCREENING TEST NORMAL FOR: PKU, AND HOM ONLY
HOSPITAL NAME:
SCREENING TEST NORMAL: HOM GAL PKU
MOM’S NAME: (last, first, initial)
HYPOTHYROIDISM
MOM’S CITY:
OHIO
MOM’S RACE: MOM’S PHONE:
MOM’S AGE: (
)
MOM’S SSN:
–
ZIP: –
SEE FOOTNOTE__________ON BACK
–
/
TIME:
/
:
(USE 24 HOUR TIME ONLY)
PHYSICIAN NAME:
CITY:
OHIO ZIP:
PHYSICIAN’S PHONE: ( SPECIAL:
)
–
MALE
PHYSICIAN PROVIDER NO:
FEMALE GRAMS
BIRTH WEIGHT:
BABY’S ID:
SPECIMEN DATE:
SPECIMEN REJECTED FOR REASON:
BABY SEX:
MOM’S COUNTY:
MOM’S ID:
ODH ONLY:
HEMOGLOBINOPATHIES
SCREENING TESTS ABNORMAL:
MOM’S ADDRESS:
PHYSICIAN ADDRESS:
L-65397
SCREENING TEST NORMAL FOR: PKU, HOM, GAL, HYPOTHYROIDISM, HEMOGLOBINOPATHIES
FILL ALL CIRCLES WITH BLOOD BLOOD MUST SOAK COMPLETELY THROUGH DO NOT APPLY BLOOD TO THIS SIDE
TEST RESULTS: BIRTHDATE
PREMATURE:
YES
NO
ANTIBIOTICS:
YES
NO
TRANSFUSION:
YES
NO
SPECIMEN:
FIRST
SECOND
SUBMITTER:
HOSPITAL / BIRTH CENTER PHYSICIAN HEALTH DEPARTMENT OTHER: (name below)
–
ODH COPY HEA 2518
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PROCEDURAL STEPS
RATIONALE
2. Identify the patient using two identifiers, and identify yourself.
Performing any procedure on the wrong patient can cause problems for the patient and using an incorrect chart can cause administrative problems.
3. Explain the procedure to the parent or caregiver. Put on gloves.
Explaining the procedure will provide comfort to the parent. Gloving provides safety to the medical assistant when coming in contact with body fluids such as blood.
4. Expose the infant’s heel and locate the position on the heel used to obtain blood. Warm with compresses for approximately five minutes.
The location provides the best access for a successful blood specimen. Warming the area increases the blood flow to the capillaries in the heel.
5. Cleanse the area with the antiseptic wipe. Allow to dry.
This prevents contamination of the sample. Do not touch the clean site. If touched, the area will need to be cleaned again.
6. Securely grasp the foot to be punctured. Using the lancet, quickly puncture the heal perpendicular to the line on the sole of the foot. Discard the lancet in the sharps container.
Securing the foot prevents excessive motion that could cause trauma during puncture. Discarding the lancet immediately prevents puncture to self or other health professionals.
7. Gently wipe the first drop of blood away with sterile gauze and discard in the biohazards container.
The first drop of blood contains excess tissue fluid along with alcohol from the antiseptic wipe, which could produce inaccurate results.
8. Gently squeeze the heel, expressing large drops of blood. The test card is placed, as per directions, on the puncture site.
Gently squeeze to expel only blood products. Excessive pressure will dilute the sample with tissue fluid.
9. Fill each circle on the test card with blood, obtained directly from the puncture site. All circles must be saturated for accurate results. Place the card aside for drying (Figure 19-17).
Providing an adequate sample allows for a more accurate evaluation.
10. Cover the puncture site with gauze and apply pressure. Maintain pressure until the bleeding has stopped.
This will assist in controlling bleeding.
11. Cover the site with a small adhesive bandage.
This will absorb any additional blood expelled during the remainder of the exam. It is also comforting to the caregiver.
12. Discard all materials in the appropriate container. Remove gloves and wash hands.
Discarding all materials in the appropriate container and handwashing will prevent the spread of any possible contaminants.
13. Document the results of the procedure in the patient record.
Every procedure must be documented in the patient record.
14. After the card is completely dry (approximately two hours), place the card in an envelope to transport to lab.
The card must be dried for best results.
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DOCUMENTATION EXAMPLE INSTRUCTIONS FOR NEWBORN SCREENING SPECIMENS
10-6-XX 0930
1. Cleanse infant’s heel with alcohol swab. 2. Puncture heel in fleshy lateral or medial posterior portion with sterile disposable lancet. Wipe puncture site with dry sterile swab. 3. Allow large blood droplet to form. Touch blood droplet to center of circle on ONE SIDE of filter paper card ONLY. Observe reverse side of card and insure that blood has soaked completely through before removing card from infant’s heel. 4. Repeat step 3 to fill ALL FIVE CIRCLES. DO NOT squeeze heel excessively to obtain blood. 5. Allow card to AIR DRY 2 hours at room temperature on a non-absorbent surface. DO NOT stack cards together while drying. 6. After blood spots are completely dry, place card in ODH self-addressed laboratory mailing envelope. MAIL within 48 HOURS. CORRECT
PKU screening per Dr. Heinz. Blood specimen obtained from medial L heel. Bleeding stopped without difficulty. Pt. comforted easily. All circles on screening card completely covered and mailed to XYZ lab at 2:30 p.m. Justin Danick, RMA
INCORRECT
FIGURE 19-17 Instructions illustrate the correct area on the infant’s heel for specimen collection. Circles must be properly filled for accurate results.
PROCEDURE 19-4 Perform a Pediatric Injection Objective: To properly administer a medication into the vastus lateralis muscle of a pediatric patient.
Equipment/Supplies ❖ ❖ ❖ ❖
Appropriate sized needle and syringe unit Antiseptic wipe 2x2 gauze sponges Adhesive bandage
PROCEDURAL STEPS 1. Wash your hands, assemble the equipment, and prepare the medication.
❖ Medication tray ❖ Sharps container ❖ Disposable gloves RATIONALE Handwashing is the number-one defense against disease transmission. The medication should be prepared before beginning the procedure. continues
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PROCEDURAL STEPS
RATIONALE
2. Identify the patient using two identifiers, identify yourself, and explain the procedure.
Giving a medication to the wrong patient can result in serious consequences to the patient.
3. Rewash your hands and don gloves.
Hands become soiled again once you touch any surfaces such as doorknobs, countertops, or the chart. Gloves should be worn when there is a possibility of contact with blood.
4. Select and locate the proper site for the injection.
The medication must be placed in the muscle for proper absorption.
5. Cleanse the site with an antiseptic and allow to completely air dry.
Allowing the alcohol to dry completely will be more comfortable for the patient.
6. Remove the needle cap and properly position the hand on the injection site. 7. Pull the skin taut and insert the needle at a 90°.
The medication needs to be delivered into the muscle.
8. Aspirate to ensure the needle is not in a blood vessel. If blood enters the syringe, immediately remove the needle, discard, and prepare a new syringe. If there is no blood return, proceed by slowly injecting the medication.
Injection of medications directly into a vessel could cause adverse reactions.
9. Remove the needle quickly at the same angle as insertion.
Removing the needle in this fashion prevents injury to the surrounding tissue.
10. Place a gauze sponge over the injection site and gently massage.
Massaging the site speeds absorption of the medication and soothes the area.
11. Engage the safety device on the needle and dispose of the entire unit in the sharps container.
Safety devices are designed to prevent needle stick injuries.
12. Apply an adhesive bandage to the site.
If there is any bleeding after the injection, the blood will be absorbed by the bandage.
13. Remove the gloves and wash your hands. 14. Document the procedure in the patient’s chart.
DOCUMENTATION EXAMPLE:
10-05-XX 1100
DTaP Inj, R. vastus lateralis, IM, per Dr. Leonard. Manufacturer: Squibb, Lot # M98760, exp. date 12-05-XX. Kaley Karnes, CMA (AAMA)
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Chapter Summary Working in pediatric health care can be a bit chaotic and stressful at times but the rewards are immeasurable. Children are often fearful of going to the “doctor” and will quite often act out their fears on the health care workers. Medical assistants should learn techniques that will help reduce the child’s fears and increase the patient’s trust. Medical assistants should become familiar with health and wellness visits and immunizations associated with each one. A proactive approach will help moms and dads learn their roles in not only protecting the child while the child is young, but in preventing adult diseases as well. Kids bring joy and laughter into the lives of the people they touch. Enjoy their inquisitiveness and the innocence in which they say and do things. A medical assistant’s days will never be dull when working in pediatrics.
FIELD APPLICATION CHALLENGE The provider orders a length and weight on a twomonth-old infant. Upon asking the 17-year-old mother to assist, she seems hesitant and nervous. The baby cries out as the mother removes the diaper. With the diaper removed, you note old fecal matter on the skin. The baby is in the lower fifth percentile for height and weight. Discuss some problems that come to mind.
1. Is there a need for some patient education? 2. What might the low weight indicate? 3. Investigate what agencies might provide assistance to the mother. 4. How can you provide a positive experience during the exam?
Chapter Assessment 1. The average heart rate of a 12-month-old is: a. 75–85 BPM. b. 60–80 BPM. c. 110–115 BPM. d. 125–135 BPM.
4. A required newborn screening test is: a. pneumonia. b. PKU. c. scoliosis. d. allergies.
2. At six months, a toddler can: a. string two to three words together. b. only listen with no response. c. complete sentences. d. babble, squeal, and produce other noises.
5. Childhood obesity can be attributed to: a. fast food. b. school nutrition programs. c. removal of physical education programs. d. genetics. e. all of the above.
3. Common reflexes seen in the infant include all of the following except: a. rooting reflex. b. sucking reflex. c. skipping reflex. d. swimming reflex.
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Web Activities 1. You are planning a trip to Africa. You are taking children that are four, six, and nine with you. Investigate the immunizations that would be required or recommended for each child going on the trip. Visit the Web sites of the World Health Organization (www.WHO.int) or the CDC (www.cdc.gov). 2. Depression, suicide, and associated disorders can be studied in depth by visiting the National Institute of Mental Health (www.nimh.nih.gov). Pamphlets used for patient education can be obtained through this site.
CONNECTION Using your StudyWARE CD-ROM: ❖ Complete the Hangman activity for this chapter. ❖ Complete the Crossword Puzzle activity for this chapter. ❖ Complete the Quiz for this chapter in Test Mode.
THE DVD LINK On your StudyWARE CD-ROM, go to the DVD Challenge for this chapter. View the DVD clip and respond to the following questions: 1. As you can see from reading the chapter and reviewing the DVD clip, there is more than one way to perform an infant weight. In regards to clothing removal, what were the differences between the contents of this chapter and the DVD clip? Which method would give you most accurate results? Why? 2. What happened to the table paper on the exam table when the medical assistant was measuring the infant? 3. Do you think that the medical assistant’s mark made at the base of the foot was reliable. Why or why not? 4. Do you think that using a caliper as described within the chapter or using a tape measure would be more accurate for measuring an infant’s height? Why?
C H A P T E R
Evaluation and Care of the Geriatric Patient Chapter Outline The Process of Aging Cognitive Functioning and Development Areas of Cognition Affected by Aging Disease Processes Alzheimer’s and Dementia Examination/Screening of the Geriatric Patient Physical Screening Vital Signs The Frail Senior
Common Diseases of the Geriatric Patient Arthritis Diabetes Osteoporosis Parkinson’s Disease Cerebrovascular Accident (CVA) Societal Issues and Concerns Senior Care and Senior Abuse Depression Nutrition and Hydration Death and Dying
20 Essential Terms activities of daily living (ADLs) ageism Alzheimer’s disease arthritis cataract cerebrovascular accident (CVA) dementia diabetes dowager’s hump frail senior geriatric geriatrician gerontologist gerontology glaucoma hospice instrumental activities of daily life (IADLs) osteoporosis palliative care Parkinson’s disease passive euthanasia continues
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retinopathy senior abuse thanatology tinnitus
Developmental Objectives After completing the chapter, you should be able to: 1. Correctly spell and define essential terms. 2. Describe the process of aging. 3. Explain the various phases of Alzheimer’s disease. 4. Differentiate between Alzheimer’s and dementia. 5. Discuss ADLs and IADLs. 6. Discuss special considerations to ponder when screening geriatric patients. 7. Differentiate between the different types of arthritis. 8. Explain the relationship between osteoporosis and fractures. 9. Outline the symptoms for Parkinson’s disease. 10. Describe the different types of stroke and the related symptoms for each type. 11. Outline five different types of abuse in the senior population and list clues that would indicate such abuse during the patient screening. 12. Discuss the nutritional needs of the senior patient. 13. Explain the purpose of hospice.
Introduction As the baby boomer generation increases in age, the number of senior patients is rising. The medical assistant must have an understanding of the multifaceted changes that occur during aging. Communication skills must be honed, not only to include conversation with the senior patient, but possibly with family members and caregivers. Certain ailments, illnesses, and limitations present challenges in the screening and assessment of the geriatric patient. The field of gerontology is the study of old age. The gerontologist or geriatrician, a health care provider that cares exclusively for older adult patients, has received advanced training to enable an understanding of changes and disease processes that occur later in life. Geriatricians are usually board certified in Family Practice or Internal Medicine and complete additional training. The number of persons aged 65 or older is expected to double within the next 25 years according to the U.S. Census Bureau. By 2030, one out of five Americans (approximately 72 million) will be age 65 or older. Women make up 20.6 million of this tally, while 14.4 million are men. The group of persons over the age of 85 is the fastest growing group in the U.S. population. Figure 20-1 illustrates the number of persons 65+ from the years 1900 to 2030 and demonstrates a vast increase in numbers projected for the coming years.
THE PROCESS OF AGING When we discuss aging or the senior patient, we are referring to patients age 65 or older. Aging occurs in two categories:
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Number of Persons 65+, 1900–2030 (numbers in millions) 80 70 60 50 40 30 20 10 0
70.3 53.7 39.7 25.7
34.4 34.8
16.7 3.1
4.9
9.0
1900 1920 1940 1960 1980 1998 2000 2010 2020 2030
Year (as of July 1)
FIGURE 20-1 A chart showing the growth in the number of persons 65 years and older from 1900 to 2030
FIGURE 20-2 Physical changes such as thinning hair, wrinkles, age spots, and change in stature due to aging
1. Primary aging: These are the physical changes, as seen in Figure 20-2, that are always attributed to aging and are typically irreversible. These might include hair texture and quantity, skin changes such as spots or wrinkles, and body shape and size. This type of aging might begin at an age earlier than 65, but is often related to getting older. 2. Secondary aging: These are the medical ailments that we often see in older patients, but are commonly related to lifestyle or health promotion throughout the patient’s lifetime. Genetics also plays a role in secondary aging. As aging occurs, changes in appearance due to primary aging along with diseases and conditions brought on by secondary aging can have an effect on a patient’s
psychological well-being. Society can often be judgmental of older adults, resulting in something called ageism. Table 20-1 illustrates some of the common physical changes that occur as a patient ages. The medical assistant, when working with the geriatric population, should be aware of these changes and should be sensitive and professional when working with members of this special population. Other changes commonly occur with aging. Although the body remains healthy in many ways, there often is a decrease in the function of the sense organs, including impairment in vision, hearing, and taste. Table 20-2 summarizes the aging process in the sensory organs.
TABLE 20-1 Signs of Primary Aging Skin
Becomes thinner, dryer, loses elasticity Wrinkles begin and blood vessels are more visible Brown spots or “age spots” increase with age (Figure 20-3)
Hair
Becomes thinner, grayer, and sometimes turns completely white due to pigment changes
Stature
Loss of height, sometimes as much as 2 inches, due to compression of the vertebra Slight bend in stature due to muscle weakness
Body shape
Weight decrease due to muscle loss and osteoporosis Redistribution of fat to torso and lower part of face
FIGURE 20-3 Brown spots can appear on the hands, face, and body due to aging and overexposure to the sun.
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TABLE 20-2 The Aging of Sense Organs VISION Cataracts
Thickening of the lens (Figure 20-4) makes vision cloudy and opaque May be helped with glasses and surgery
Glaucoma
Increased pressure in the eye Causes optic nerve damage Treated with eye medication (review instillation of eye drops in Chapter 13)
Senile macular degeneration (SMD)
Deterioration of the retina can cause loss of central FIGURE 20-4 An opaque area in the center of the eye is a cataract. vision, but generally does not affect peripheral vision Visual acuity tests may help with diagnosis (refer to Chapter 13) May require laser surgery or photodynamic therapy that includes the injection of a substance called Visudyne, which circulates to the abnormal blood vessels in the eye
HEARING Conversational
One third of older adults are affected Certain tones and pitches are difficult to hear
Background noise
Often a problem in a noisy environment
Directional
Unable to tell the direction of the sound
Tinnitus
Buzzing or ringing in the ears
TASTE Loss of desire to eat
Various flavors or tastes will be harder to differentiate due to the loss of taste buds in the mouth
Aging not only affects appearance and the sensory organs but can have a profound effect on all body systems. Table 20-3 lists body systems along with agerelated changes that can occur. Medical screening by the medical assistant might prove to be the initial means for identifying a change in these processes related to aging. Often, the patient
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F IEL D S M A R T S It is important to remember that aging is not synonymous with disease or illness. With developments in new treatment methods for chronic as well as acute illnesses, people are living longer and having a better quality of life.
will deny any deterioration, hindering possible adjustments or treatments. The patient, for example, may avoid a hearing test because a hearing aid would indicate aging and create a perceived negative stigma. Yet a hearing aid might be the important tool needed to avoid loss of socialization. Adjustments are often difficult for family members as well. Primary aging is inevitable. The goal is to maintain the highest quality of life while being able to continue with activities of daily living (ADLs).
COGNITIVE FUNCTIONING AND DEVELOPMENT As we all age, our intellectual abilities change. All senior patients may demonstrate some decline in functioning, but patients will differ in how they exhibit and experience the changes. Geriatric patients have had many years of relevant learning and life experiences. These
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TABLE 20-3 Age-Related Changes within the Body Systems SPECIFIC BODY SYSTEM
POSSIBLE AGE-RELATED CHANGES
Nervous system
Brain shrinks an average of 10% between the ages of 30 and 90 No change in attention span Longer time needed to learn new things Language usually remains the same
Circulatory system
Plaque buildup on artery walls due to arteriosclerosis can decrease the amount of blood flow to the body Development of hypertension is common Development of coronary artery disease
Respiratory/pulmonary system
Decrease in oxygen exchange occurs due to stiffening of the chest wall and loss of elasticity of the lungs
Digestive/gastrointestinal system
Decrease in production of gastric juices Increase in constipation due to a decrease in peristalsis Malabsorption of some nutrients
Urinary system
Enlarged prostate in males Weakened bladder muscles resulting in incontinence Less efficient kidneys
Musculoskeletal system
Decrease in muscle mass Weight gain Decrease in bone density Joint cartilage deteriorates
Endocrine system
Decline in female hormone estrogen and male hormone testosterone and development of thyroid changes resulting in either hypothyroidism or hyperthyroidism
Areas of Cognition Affected by Aging Areas of cognition that can be affected by the aging process include:
❖ Sensory storage: It is often difficult to store information gained from the sensory organs because older adults may not be able to see or hear adequately. Poor lighting and loud background noise can make it difficult to store this information.
PAT I E N T T U T O R There can be many contributing factors for a decline in cognitive function among the aging population. Some factors can be changed while others cannot. Factors include:
❖ High levels of stress ❖ Diseases that decrease blood flow to the brain, such as heart disease, diabetes, and high blood pressure.
❖ ❖ ❖ ❖
It is important to educate patients on factors they can change and how to best manage those they cannot.
Sedentary lifestyle Social isolation Low level of education Tobacco and other substance abuse
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past experiences will assist in how they interpret and classify new information.
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❖ Working memory: This type of memory stores and processes information similar to a computer. Due to a decline in cognitive function, senior patients may have to read something several times in order to process the information. ❖ Knowledge base: This consists of all the information stored in one’s memory. This base can become diminished in older adults. ❖ Unconscious or implicit memory: This is made up of a person’s routines, emotions, and instinct. There may or may not be a decline in this area. ❖ Explicit memory: This is learned information, which may be more difficult for the senior patient to remember. ❖ Long-term memory: This type of memory may be easier for the patient than short-term memory. Medical assistants must be aware of a patient’s cognitive limitations to avoid embarrassing the patient and the patient’s family. These types of deficiencies are often a source of great frustration for anyone involved in the communication process with a senior patient.
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PA TIEN T P E R SP E C T I V E There is so much paperwork to read and fill out as I wait for the physician. The print is so small on these forms, and I don’t understand some of the language. The waiting room is so noisy and I am having trouble concentrating. I wonder why the medical assistant is making me fill out these forms myself, instead of offering to help me? (See Figure 20-5a.)
(a)
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F IEL D S M A R T S Allow the older adult ample time for new paperwork or any reading of health information. Make sure there is adequate lighting. You may need to place the patient in a quiet exam room or education room rather than the reception area. It is difficult for the older adult to perform any task while trying to ignore other sensory distractions. (See Figure 20-5b.)
(b)
FIGURE 20-5 (a) The patient is distracted, confused, and frustrated due to the noise in the waiting area, which makes it hard to concentrate. (b) The patient is much more at ease in quiet surroundings where she can concentrate.
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CR ITI C A L TH I N K I N G C H AL LEN G E While interviewing a 70-year-old male patient, you notice that he is not thinking as clearly as he was during his last appointment three months ago. 1. What causes, besides a disease process, could be contributing to this decrease in cognitive function?
Disease Processes Many illnesses and diseases may be responsible for causing changes in cognition. Cardiovascular changes can decrease blood flow to the brain. A compromised immune system might allow an infectious process to occur and can also cause fatigue. Cancer may create deficiencies directly from the tumor itself or due to metastasis from various sites. Depression may be the culprit and can be very harmful in older adults. Although these disease processes may not be caused by aging exclusively, they may cause sensory deficiencies, which can have a direct affect on cognitive function. A specific disease process that is often blamed for mental problems is dementia or senility.
Alzheimer’s and Dementia A frightening diagnosis for families and patients is when they are told they have Alzheimer’s disease. Although
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this is the most common form of dementia, there is no known cure to date. In the past, it was believed that only younger adults with recall difficulties had this dreaded disease. The older patients were only senile. This is no longer the acceptable description. Alzheimer’s disease occurs when certain areas of the brain that control thinking, communication, and behavior deteriorate. Some of the deterioration may be caused by a decrease of the neurotransmitter acetylcholine. Correct levels of this neurotransmitter are needed for the nerve cells in the brain to work properly and a decrease creates difficulty with memory, decision making, and daily living. As the disease progresses, the level of independence diminishes, requiring increased care by family members and facilities specializing in the treatment of Alzheimer’s patients. Diagnosis is not usually determined immediately as the onset may prove subtle. The patient may have difficulty remembering some things, but often attributes this to “too much on my mind,” “too busy,” or “too stressed.” However, the level of forgetfulness or confusion continues to increase. Everyday familiar tasks, such as cooking, cleaning, and bathing, may begin to be difficult. Poor judgment begins to be noticed, such as going to the store with pajamas on, getting lost when driving to familiar locations, or placing car keys in the refrigerator. Other conditions might cause similar symptoms, so one must use caution when diagnosing dementia or Alzheimer’s disease. Head injuries, depression, and certain medications may also be the cause. All other factors must be ruled out before making a diagnosis. Three types of Alzheimer’s disease have been described, as seen in Table 20-4. Although some are
TABLE 20-4 Types of Alzheimer’s Disease TYPE
DEFINITION
DESCRIPTION
Early onset
Diagnosis of patients under age 65
Genetic defect Memory loss Muscle twitching and spasm Premature aging
Late onset Sporadic Alzheimer’s disease
Occurs after age 65
Memory loss that is frequent Repeats questions and statements Change in personality Gets lost easily Argumentative
Familial Alzheimer’s disease
Extremely rare Entirely inherited Early onset (40s)
Less than 1% of all cases Must have at least two previous generations involved
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diagnosed before the patient is older, the disease continues into the later years. The debilitating prognosis can extend from two years up to 20 years. Memory may be affected first, but other brain cells will gradually be targeted leading to the need for complete care with the eventual outcome being death. Other types of dementia have been identified, some of which are treatable. Alarmingly, the incidence of dementia seems to be on the rise in older adults. The reason is unclear, with the possibility being that more people are living longer. Subsequently, there is more time and chance to develop a disease. Symptoms include personality changes, possible mood swings, and behavior alterations. A challenge to mental functions may be mild or severe. Causes of dementia, mostly correctable, are: ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖
Depression Medications Drugs and alcohol Hormone imbalances Vitamin deficiencies, such as B12 Head injury, subdural hematoma Tumors Hypothyroidism Hypoglycemia CNS infections, such as tertiary syphilis
Others causes of dementia that are not treatable are: ❖ Multi-infarct dementia (stroke) ❖ AIDS dementia, caused by the HIV virus itself, which damages brain cells ❖ Creutzfeldt Jakob disease (CJD), an extremely rare degenerative brain disorder ❖ Microvascular disease of the brain, found in many diabetics Although cognitive functioning and development seem to diminish to varying degrees in older adults— often leading to dementia as age increases—some lim-
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PA TIEN T P E R SP E C T I V E Do they not know I am sitting right here? I may be old, but I’m not dead. They are talking to my daughter instead of me. I can converse well with anyone, and I just wish they would treat me as an adult instead of a child.
ited areas of cognition and sense appear to heighten with age. Aesthetic senses and appreciation of nature tends to increase in old age. Creativity may be rediscovered and wisdom certainly surfaces and becomes apparent. As health care workers interact with the senior patient, these changes in life, either positive or negative, must be considered and incorporated into the screening, assessment, and provision of care.
EXAMINATION/SCREENING OF THE GERIATRIC PATIENT When initially screening the geriatric patient, some special considerations might need to be addressed. Physical limitations need to be considered along with communication. As with the pediatric patient, communication may involve caregivers in addition to the patient. The geriatric patient may exhibit hearing deficiencies. Do not assume that the patient cannot hear because the patient is older. This will need to be determined during the screening process. Hearing tests, as described in Chapter 13, will assist in this determination. Chapter 8 lists tips for working with patients with hearing aids and hearing disorders.
Physical Screening After greeting the geriatric patient, the medical assistant will visually inspect the patient. This begins at the beginning of the encounter. Review Table 20-5 for physical screening evaluation tools. Questions that medical assistants should ask themselves are included. Even though the majority of these items will be assessed by the provider, the medical assistant should share any observations with the provider.
Vital Signs Although the procedures for obtaining vitals will be the same as those for the adult patient (refer to procedures
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FI E L D S M A R T S One trick for increasing the patient’s ability to hear is to use a reverse stethoscope. Clean the ear pieces of your stethoscope with alcohol and place in the patient’s ears. Speak (don’t yell) into the bell. It will amplify your voice. Be sure to cleanse your earpieces before using again.
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TABLE 20-5 Initial Screening Observations for the Medical Assistant Stature and gait
Is the patient more stooped over than before? Is the patient stable while standing? Is the patient shuffling when walking? Is there a limp? Does the patient need assistance when walking?
Skin
What are the skin tones? Blue? Gray? Ashen? Pale? Red? Are there skin lesions? Is there bruising or lacerations? Is the patient jaundiced? Yellow eyes?
Odors
Is there excessive body odor? Are the patient’s clothes clean or in disarray? Is there an odor from the oral cavity?
Weight
Is there excessive weight gain or loss?
Mental status
Does the patient follow directions? Is the patient aware of where she is and why she is there?
in Chapter 11), some special considerations might be necessary for the geriatric patient. ❖ Use the appropriate size cuff for the patient when taking a blood pressure. If the patient is frail and thin, a pediatric cuff might be best. ❖ When touching the skin, be cautious of bruising and tearing of tender tissues. ❖ Use caution when weighing the patient. Provide adequate support, as shown in Figure 20-6, when the patient is stepping up and standing on the scale. Be prepared for unsteadiness. Do not walk away from the geriatric patient on the scale. ❖ Use caution when assisting the patient to the exam table. Use good judgment when determining if a patient can be left unattended on the table. Consider the mental and physical status of the patient, along with accompanying caregivers. ❖ Geriatric patients are often cold. Be considerate when preparing the patient for the examination. An additional drape may be needed.
The Frail Senior The frail senior patient is defined as one who cannot complete three or more ADLs independently. These include bathing, eating, dressing, walking, and using the restroom. Other culturally defined activities are also important for maintaining independence. These are considered instrumental activities of daily life (IADL). These would include areas that require intellectual ability. In the United States, these areas might
FIGURE 20-6 The medical assistant helps the senior patient onto the scale.
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include grocery shopping, making appointments with health care providers, taking medications, paying bills, and keeping the household functioning. As the number of senior patients increases, the care of the frail patient needs to be considered. Often caregivers and family members are now involved in the office visits. This may include the spouse or adult children. Observe the relationships shown in Figure 20-7.
FIGURE 20-7 (a) The medical assistant speaks with the patient and his spouse. (b) Often other family members such as adult children are involved in a senior’s care. (a)
Home health nurses might be incorporated and nursing homes may be transporting patients for medical appointments. Caring for the frail senior patient is a community effort.
COMMON DISEASES OF THE GERIATRIC PATIENT Although aging is not synonymous with disease or illness, there are some disease processes we see more as the patient ages. These illnesses are not exclusive to the senior patient. As our body ages, changes in the anatomy and physiology of our systems may promote some health disorders.
Arthritis About half of the population over the age of 65 has some type of arthritis, with the most common type being osteoarthritis. This is not necessarily considered a natural part of aging. It might be due to genetics, injury, obesity, or inactivity. Arthritis refers to an inflammation within a joint, which might present with pain, swelling, redness, heat, and stiffness. Several types of arthritis are described in Table 20-6. Causes of arthritis are not as clear as the factors that increase the risk for arthritis. (b)
❖ Gender: Women have more cases of arthritis than men. ❖ Weight: Obesity causes more stress on joints, causing excessive wear and tear.
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PATIENT TUTOR When cleared with the provider, an exercise program for osteoarthritis that is nonstrenuous and not painful may be prescribed. It usually starts with flexibility exercises. These increase range of motion, decrease stiffness, and protect tissues from getting too tight. Stretching should be done comfortably and slowly. The next set of exercises might include strengthening the muscles that support the joints. Aerobic exercises, such as swimming, biking, or Tai Chi may also be incorporated. A member of the geriatric health care team can set up the program for each individual patient.
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TABLE 20-6 Types and Descriptions of Arthritis Osteoarthritis
This can occur in any joint. It develops when the cartilage that covers the bone ends degenerates, causing the bones to rub together. This is also called degenerative joint disease.
Rheumatoid arthritis
This occurs when the immune system attacks the body, causing inflammation within the joints, which damages the cartilage. This is chronic, long term, and affects organs in addition to bone.
Gout
This results from excess uric acid in the body, which forms crystals in the joints. There is severe pain and swelling, and often redness and warmth. This is commonly seen in the big toe, but can also affect the knees and wrist joints.
❖ Environment: Repetitive actions, often work related, cause excessive wear on certain joints. Prior injuries, job or athletic related, commonly result in arthritic problems in later years.
Diabetes Approximately 13 million Americans currently are diagnosed with diabetes, the majority being type 2 diabetes. This type is more prevalent in geriatric patients because, as the body ages, there is less tolerance to glucose. In type 2, the body produces insulin but cannot utilize it correctly; therefore, there is an elevation in blood sugar. This is in contrast to type 1, in which the body destroys the beta cells in the pancreas that produce insulin, resulting in decreased insulin production. Blood tests, as illustrated in Chapter 30, will show the normal ranges for glucose in the blood. The main concerns related to diabetes are the secondary problems associated with the disease, which are often serious for the geriatric patient. If the disease progresses unchecked, dehydration, retinopathy, kidney damage, and poor circulation may occur. Prevention of these complications is related to control of the disease.
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PA TIEN T P E R SP E C T I V E I don’t understand all of this stuff about insulin and blood sugar that everyone keeps talking about. I eat well, not a lot of sweets. Why am I having this problem? It would be very helpful if the medical assistant could give me some written information about my condition and go over it with me before I leave the office.
Osteoporosis Depending upon bone strength early in life, genetics, and how bones are cared for with diet, supplements, and exercise, a patient’s bones can become thinner and more porous, leading to the disease osteoporosis. Major bones that are important to the geriatric patient such as the hips, pelvis, and vertebrae, may become thin and weak. During the screening of the geriatric patient, height should be recorded consistently along with any stooped stature, which might be an indication of osteoporosis. A dowager’s hump, as illustrated in Figure 20-8, is when the upper back becomes extremely curved.
FIGURE 20-8 A curvature of the spine or dowager’s hump is caused by osteoporosis, making it impossible to straighten the spine.
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Type 1 and type 2 diabetes are very different physiologically. Refer patients to educational materials that will supply a good background on what insulin does in each type. A thorough understanding will increase compliance with any health protocols established for that patient. In summary:
❖ Type 2: Foods are converted into sugars, triggering the need for insulin. The pancreas produces the insulin but the cells are resistant to it, which causes the pancreas to produce more. Because the sugars are not removed from the bloodstream, the glucose level rises.
❖ The hormone insulin is needed to attach to glucose cells in order to store them to be used for energy. ❖ Type 1: Beta cells in the pancreas are destroyed, which decreases the production of insulin. Blood glucose cannot be controlled, causing an increase in sugar levels.
Symptoms of diabetes may include: increased thirst, increased hunger, increased and frequent urination, dry mouth, fatigue, blurring of vision, increased number of infections, and circulatory problems in the hands and feet. Any given patient may not have all symptoms.
Another symptom of osteoporosis is an increase in fractures. As the patient ages, the health providers see an increase in hip, vertebral, and wrist fractures. When senior patients fall, it usually prompts the question, “Did the patient fall and fracture a hip, or did the fracture occur due to osteoporosis causing the patient to fall?” Treatment of the disease is necessary to prevent further fractures. A diagnosis of osteoporosis is based upon a patient’s medical history, physical exam, and a bone density test, which is a scan of the hips and spine. It is recommended that all women have a bone density test beginning at menopause. If a woman is at high risk for developing the disease due to family history or physical symptoms, it is recommended that bone density
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P ATIEN T TU T OR Lifestyle and diet changes are prescribed for osteoporosis. Diets that include supplements rich in calcium and vitamin D are important. Exercises, including controlled weight lifting, may be helpful in increasing bone density. Walking is important for the strength of the hips. Reinforce health clearances by the provider before starting any new physical activity.
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screenings begin at an earlier age. The medical assistant will schedule the exam for the patient and will be the one to provide patient education about the bone density test.
Parkinson’s Disease Parkinson’s disease is a chronic neurological disease, which inhibits the production of dopamine. The substantia nigra is a section of the brain housing the cells that produce this important neurotransmitter. Dopamine is important in the coordination of movement and balance. If these cells are destroyed, as they are in Parkinson’s disease, body movements are altered.
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PATIENT TUTOR Concerning medications, remind patients not to take capsules apart or split pills as this may prevent appropriate drug absorption. Patients should stay hydrated with 6 to 12 glasses of water daily. They should be familiar with side effects and carry a record of their drugs with them at all times. Make sure patients include OTC medications and herbal medications in their list. These are commonly overlooked.
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Three out of 100 seniors are diagnosed with Parkinson’s disease and it is more commonly seen in men. Some are diagnosed at an earlier age. Symptoms include tremors, rigidity of muscles, loss of balance, falling, speech changes, shuffling when walking, and slowing of movements. At this time, there is no known cure for Parkinson’s. Genetic and environmental causes are currently being researched. Management of symptoms is the current trend in an effort to maintain the highest quality of life possible. Medications are prescribed to improve mobility, decrease tremors, improve posture, and maintain mental abilities. Surgical intervention may be considered if drug therapy is unsuccessful. Great strides are being made in stem cell research to treat diseases such as Parkinson’s.
Cerebrovascular Accident (CVA) Cerebrovascular accident (CVA) is commonly referred to as a stroke. This refers to the death of a portion of the brain due to lack of blood flow and oxygen to that area. Symptoms vary depending on the cause and the area of the brain affected. Refer to Table 20-7 for more information on stroke or CVA.
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FI E L D S M A R T S If a patient calls the office with symptoms of a CVA or TIA, call 911 immediately. The faster the patient receives intervention in the emergency room setting, the better the outcome. If the patient is suffering from an acute ischemic stroke (blood clot blocking an artery) and the clotbusting drug tPA (tissue plasminogen activator) is administered within three hours of the onset of symptoms, there is a decrease in the disabilities caused by the stroke.
Treatment often involves an entire team of health care workers, including rehabilitation and therapy workers. A CT scan and MRI will assist in diagnosing the cause to enable appropriate treatment. Refer to Chapter 31 for an explanation of these procedures. Improving blood flow to the area is essential and early medical intervention facilitates this. Rehabilitation will
TABLE 20-7 Stroke or CVA TYPE OF STROKE OR CVA
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CAUSES
SYMPTOMS
Ischemic
Blockage of the artery that supplies blood to the brain May be due to a clot Blood flow may also be reduced due to another heart condition
Symptoms usually occur on the opposite side of the body from the brain injury Paralysis on one side of the body Difficulty with vision Confusion Difficulty speaking and understanding Severe headache May be sudden or progress over days
Hemorrhagic
An artery leaks blood or ruptures in the brain
May be similar to ischemic except: Very severe headache Nausea/vomiting Dizziness Seizures, confusion Loss of consciousness Stiffness of neck Usually occurs during some type of activity
Transient ischemic attack (TIA)
Mini-strokes
Similar to stroke but temporary Usually improves within 20 minutes
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PA TIEN T P E R SP E C T I V E
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I feel so useless since I had my stroke. I can’t walk, feed, or dress myself, and I can’t find the right words when I try to talk. I feel like such a burden to my family. Maybe it would have been better if I had died instead of causing all this trouble.
As the patient returns to the medical office for follow up and care after a stroke, it is important to provide positive support for the patient and family alike. The family members are often in need of medical and psychological guidance. Be prepared to recommend support groups and resource material. Be an empathetic listener.
begin in the hospital and continue at an outpatient facility. The amount of rehabilitation will be based on the amount of damage that the patient sustains as a result of the stroke. A team of rehabilitation specialists including physiatrists (providers of physical medicine), occupational therapists, speech therapists, and physical therapists will map out a rehabilitation program to help the patient regain functioning lost by the stroke.
SOCIETAL ISSUES AND CONCERNS As our society continues to increase in age, many challenges develop that need to be addressed. Many senior patients are often alone and unable to care for themselves. Others receive care from family and friends, often creating additional stress on the caregiver. Many organizations have been developed to study and assist in the care of the geriatric patient. As this population grows, other problems and concerns come to the forefront.
Senior Care and Senior Abuse As more senior patients want to stay in a home environment, more families are called upon to provide the needed care. This can prove to be a rewarding experience for all involved. It draws generations together again, and grandparents are becoming part of the nuclear family. Conversely, it also presents some challenges for families: financially, physically, emotionally, and psychologically. New skills must be learned by family members as many seniors need assistance with medical treatments. Relationships need to be developed that may not have existed in the past. For example, helping a parent bathe and use the restroom requires a different level of interaction than in the past. Roles are often reversed. Family members must also have time and support to provide care for themselves in order to maintain their own individual quality of life. It is also important to help the patient retain independence to
the highest degree possible. All of this can be fulfilling, yet exhausting. Senior care may also involve the use of a temporary nursing home stay, a permanent long-term skilled nursing facility, or an assisted living facility, depending on the level of care required. A temporary nursing home stay might be required when a patient is recovering from an illness or injury while a skilled nursing facility provides 24-hour care. An assisted living facility allows residents to maintain most of their independence and dignity while providing assistance with activities such as bathing, dressing, or cooking. Adult day care centers provide an atmosphere where patients who live with a family member can go during the day while their family members work. Patients can socialize, eat their meals, participate in different forms of recreation, and even receive some therapies. Deciding on the level of care available is often a difficult decision. It is one that must be taken seriously and discussed honestly. Communication must be open between all parties, including the health care team. At times, this relationship fails, either at home or in a facility. This may create a dangerous or abusive situation, referred to as senior abuse. Refer to Table 20-8 to help identify signs of abuse.
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FI E L D S M A R T S During screening, you should be familiar with the signs of abuse. It is a requirement that any health provider report any suspected abuse to the appropriate agencies for investigation. This might be a difficult task, but is necessary.
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TABLE 20-8 Signs of Senior Abuse TYPE OF ABUSE
DEFINITION
SIGNS AND SYMPTOMS
Physical abuse (Figure 20-9)
Hitting, pushing, scratching, slapping, kicking, burning, pinching, restraining, force feeding, drugging
Bruising, black eyes, welts, rope marks, cuts Fractures Open wounds Dislocations Broken glasses Unprescribed medications found in the blood after testing Change in behavior
Sexual abuse
Nonconsensual touching, rape, sodomy, sexual photography
Bruises at genitals or breasts Venereal disease, genital infections Vaginal bleeding, anal bleeding Torn or bloody underwear
Emotional abuse
Verbal assaults, threats, intimidation, humiliation, insults, isolating socially
Agitated Withdrawn Rocking behavior
Neglect (Figure 20-10)
Refusing duties or responsibilities to the patient Not providing food, water, clothing, payments for care, hygiene
Malnutrition Dehydration Unsanitary conditions, lice, fleas, dirty clothing, fecal smell
Abandonment
Deserting the patient
Patient left alone at home or in a facility
Exploitation
Forging checks, stealing possessions, coercion into signing papers
Forged signatures on medical statements and checks Valuables missing Funds withdrawn from financial institution
Self-neglect
The patient behaves in a manner that threatens the patient’s health and safety
Malnutrition Dehydration Lack of clothing Fecal smell Lack of medical aids, such as glasses, dentures, etc.
FIGURE 20-9 The medical assistant notices bruises on the patient’s arm.
FIGURE 20-10 The patient appears to be disheveled with dirty hair and stained clothing, which may be signs of neglect.
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CR ITI C A L TH I N K I N G C H AL LEN G E
FI E L D S M A R T S
While you are helping a senior male patient get ready for the provider’s exam, he tells you that he has not been feeling very well because he hasn’t been eating very much lately. He says his medications are so expensive that there is no money left for food. He can’t drive anymore, so he can’t even visit his local food pantry. 1. What assistance can you offer this patient? 2. What other options may be available to him?
Depression Depression in older adults is becoming more common, and yet it is often undiagnosed. About 6 million seniors over the age of 65 suffer from depression, with only about 15% being diagnosed. The missed diagnosis is commonly due to the fact that depression symptoms may be attributed to other illnesses or disease processes. It tends to last longer in geriatric patients because the initial symptoms are overlooked, which can slow treatment. Situations in later life contribute to depression. Loss of family members, spouses, and friends break down the social systems of the patient. This—combined with retirement and relocation of housing, often to more assisted living—increases the likelihood of depression. Studies have also shown that depression accompanied with physical illness increases the risk of death from the illness. Depression also increases the risk of suicide in senior patients, with the white male being at the highest risk level. Patients with severe illness such as stroke or cancer are at great risk for depression. One in five can have severe depression. Medications or the combination of many different ones may also be responsible for causing depression. Professional health providers, including the medical assistant, should be able to identify risk factors for depression seen in the older adult population. They include, but are not limited to: ❖ Recent death of loved one ❖ Isolation
When interviewing the geriatric patient and family, be sure to use active listening skills. Listen for clues that might indicate depression or abuse. Observe the body language of both the patient and the caregiver. Inform the provider if any risk factors are evident.
❖ Severe or chronic pain ❖ Substance abuse, such as alcohol ❖ Damage to body, such as amputation or heart attack ❖ History of depression ❖ Suicide attempt Fortunately, treatment for depression in older adults can be successful. It includes medication, electroconvulsive therapy, and psychotherapy. The goal is not only to recover from the depression, but to stay well long term. Treatment often continues for an extended period of time after remission.
Nutrition and Hydration As people age, their metabolism typically slows down. At the same time, older adults may be losing their sense of taste and smell. Food may no longer seem that interesting to senior patients. If they are living alone, cooking for one is often difficult, if not depressing. As they decrease calories, it is important that the calories they get are high in nutrients that are required for maintenance of health. As patients become underweight, they are more prone to balance disturbances, which may cause falls. Illnesses and problems attributed to aging may be related to poor nutrition. Nutritional deficiencies can be responsible for fatigue, insomnia, depression, poor eyesight and hearing, and anorexia. Weight loss might also signify another illness, such as cancer or heart disease. Dementia may also contribute to loss of weight. Increased weight loss may compromise the immune system, which can promote further illness. Treatment of associated diseases along with nutritional counseling may help increase the appetite, improving the overall health of the geriatric patient. Dehydration is another critical concern with geriatric patients. This can occur with excessive diarrhea, vomiting, fever, or just poor fluid intake. Replacement
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of fluids is essential for the health of the patient. Dehydration can be life threatening if not treated rapidly. Symptoms of dehydration include: ❖ Dark concentrated urine ❖ Excessive thirst (this may not be present in some senior patients) ❖ Fatigue ❖ Dizziness ❖ Confusion Suggestions for fluid replacement include offering clear liquids, including broths, teas, juices, ginger ale, Gatorade (or equivalent), and popsicles. Avoid anything that promotes diarrhea. Offer drinks between meals to avoid cramping. Provide smaller, more frequent meals and lower amounts of fiber if diarrhea occurs. Replenish potassium and magnesium if diarrhea is the cause of the dehydration. If fluid depletion cannot be resolved, emergency care may be needed. Intravenous fluids can be administered to replenish body fluids in a hospital, extended care facility, and even at home. Nutrition and hydration are essential for health. Proper nutrients and fluids are a necessary part of the overall senior health plan, and may prevent or slow the process of aging.
Death and Dying As the geriatric patient ages, the possibility of death may arise. Even though all individuals will die at some time, perceptions of death are very individualized. Research that studies death is called thanatology. The age of the patient, the patient’s culture, and past experiences will influence the patient’s responses to impending death. The health team, including the medical assistant, needs to be supportive of the patient’s and the caregiver’s
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emotions. Personal desires, including the location of death, need to be discussed. Many theories have been developed over time regarding patient views on death. The most widely published has been Elisabeth Kubler-Ross’s five stages of death and dying: denial, anger, bargaining, depression, and acceptance. The order and all inclusiveness of this process have been since refuted by other researchers. What Kubler-Ross did do, though, was open communication with dying patients, which was often avoided. This provided health providers a chance to understand the individual and unique desires of each dying patient. Deciding the way to die is often challenging to the caregivers of the patient. Living wills that are developed and discussed prior to significant illness make these decisions easier as these documents explain and outline the desires of the patient. Otherwise, these decisions are often difficult during an emotional period. The patient may request only palliative care, or care only to relieve suffering and provide dignity. No resuscitative measures are provided, often documented as DNR (do not resuscitate) on the patient’s record. The patient may request passive euthanasia, allowing the patient to die with dignity and withholding procedures or drugs that would be implemented to prolong life, which may result in prolonged misery. Controversies arise when assisted suicide or active euthanasia are discussed. Currently, Oregon is the only state with legislation allowing physician-assisted suicide. End-of-life decisions are constantly being challenged in the legislature, along with the religious arenas. Improving technology and medical advancements may create further dilemmas related to prolonging life.
Hospice One option that allows a dignified and caring end of life for the terminally ill patient is hospice. Patients accepted into hospice care have been diagnosed as having no reasonable chance of survival. The patients are
E M R A P P L I C AT I O N Many EMR programs have a patient education section that stores patient handouts. These fact sheets may be printed off for the patient at the point of care or may be e-mailed to the patient. Many older adults have computers and access to the Internet. Storing the patient’s e-mail address within the EMR software will allow you to send the patient handouts, lab test results, appointment reminders, and even some holiday cards— all with a click of a button.
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FI E L D S M A R T S You should evaluate your own ethical beliefs and standards. These should not be imposed upon dying patients or their families. They also should not infringe on the medical care a patient receives.
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allowed to die with dignity in the home or hospice setting. A team of mental and physical health providers offers assistance to the patient and family through the dying process. Volunteers are also a large part of the hospice program. One goal of hospice is to meet the needs of the patient along with the family. Helping the patient
understand how to live while dying is emphasized. Teaching the family to become supportive caregivers assists all involved. Often it is difficult to say goodbye, so the support and strength to do so is provided. Hospice is also involved in bereavement counseling for the family to assist in healing after the loss of a loved one.
Chapter Summary Being involved in the care of the geriatric patient can be a challenging as well as rewarding experience. Many have the misconception that all geriatric patients are frail and have chronic illnesses. However, with advances in medicine, many people are living well beyond their expected life span and doing so in an active and healthy manner. While aging creates health problems that are unique to this patient population, it is important to be able to communicate with geriatric patients and to educate them about their health issues on a level that is easy for them to comprehend. Health concerns that affect geriatric patients include not only their physical health but their mental and emotional status, as well as their nutritional health. Medical assistants must be observant and skilled when screening the geriatric patient to alert the provider to possible signs that may not be evident at the time of the patient’s evaluation. Don’t forget that a kind word or touch can do wonders for the geriatric patient. More information about communicating with seniors is found in Chapter 8.
FIELD APPLICATION CHALLENGE When taking Mr. King, an 86-year-old male patient, back to the exam room, you notice a slight odor of stool. While taking his vitals, you see that his nails are unkempt and dirty. The provider wants an apical pulse so you help remove Mr. King’s shirt and offer him a gown. You notice bruising and tenderness on his back. A weight check shows a loss of 20 pounds since his last checkup six months ago. Mr. King tells you his dog just died and he moved in with his daughter and her four kids one month ago. “Boy, I miss my house and dog. The kids are so noisy but I love them. I think, though, I am in the way because I can’t do much to help my daughter.” As you talk, you notice his dentures are dirty and
one stem of his glasses is missing. He sits slumped on the exam table. 1. What might these observations suggest? Is this abuse? Depression? Support your choices. 2. Discuss how you could relay this information to the provider. Do you think the daughter should be involved in the discussion of care? 3. Discuss the signs of abuse and depression and how they can be related to each other. What other areas can be explored to evaluate the care that Mr. King requires?
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Chapter Assessment
Web Activities
1. Signs of primary aging include: a. wrinkled skin. b. kidney failure. c. hypertension. d. osteoporosis.
1. Explore the American Geriatric Society Web site, www.americangeriatrics.org, for free seminars on topics related to aging.
2. Causes of dementia that are treatable are: a. Alzheimer’s disease. b. depression. c. medication reactions. d. b and c. 3. Types of senior abuse include: a. physical. b. exploitation. c. sexual. d. emotional. e. all of the above. 4. A recommendation for prevention of osteoporosis is: a. removal of any weight lifting. b. a diet low in vitamin D. c. supplements of calcium and vitamin D. d. limitation of walking. 5. Underlying causes of depression are: a. death of a loved one. b. substance abuse. c. chronic pain. d. all of the above. e. a and c only.
2. To assist families caring for geriatric patients at home, www.healthinaging.org provides a handbook on senior care. 3. Visit www.hospicenet.com and list the services that hospice provides. Also look up the nearest hospice in your area and visit their Web site if possible.
CONNECTION Using your StudyWARE CD-ROM: ❖ Complete the Concentration activity for this chapter. ❖ Complete the Crossword Puzzle activity for this chapter. ❖ Complete the Quiz for this chapter in Test Mode.
C H A P T E R
Orthopedics, Rehabilitation, and Physical Therapy Chapter Outline Types of Providers Who Specialize in Treating Diseases and Disorders of the Musculoskeletal System Patient Screening for the Musculoskeletal System Assisting with the Orthopedic Exam Common Diagnostic Procedures Performed on Orthopedic Patients Strains, Sprains, Fractures, and Dislocations Casts Other Immobilization Devices
Alternative Treatment Methods Orthopedic Surgical Procedures Treatment Options for Arthritis Rehabilitation Physical Therapists and Occupational Therapists Thermal Modalities Ultrasound Hydrotherapy Exercise Electrical Stimulation of Muscles Ambulatory Assistive Devices Canes Crutches Walkers Wheelchairs
21 Essential Terms ambulation arthritis arthroscopy assistive device cartilage cast cryotherapy dislocation fracture massage modality neurologist occupational therapist (OT) orthopedist physiatrist physical therapist (PT) physical therapy prosthesis range of motion (ROM) reduction rehabilitation continues
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Administering Heat Therapy Treatments
III.C.3.b.4.f
VI.A.1.a.4.h
Administering Cold Therapy Treatments
III.C.3.b.4.f
VI.A.1.a.4.h
Instruct a Patient to Use a Cane
III.C.3.c.3.b
VI.A.1.a.7.b
Instruct a Patient to Use Axillary Crutches
III.C.3.c.3.b
VI.A.1.a.7.b
Instruct a Patient to Use a Walker
III.C.3.c.3.b
VI.A.1.a.7.b
Assisting a Patient from the Wheelchair to the Exam Table and Back to the Wheelchair
III.C.3.b.4.e III.C.3.b.4.f
VI.A.1.a.4.b
splint sprain strain thermotherapy ultrasound vasodilation
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Developmental Objectives After completing this chapter, you should be able to: 1. Correctly spell and define the essential terms. 2. Explain the duties of the general orthopedist. 3. Explain the use of arthroscopy and electromyography. 4. Compare and contrast the difference between a strain and a sprain. 5. Describe an open reduction and a closed reduction. 6. List and define the different types of fractures. 7. List four indications for joint replacement. 8. Explain the difference between physical therapy and occupational therapy. 9. Describe the different types of hot and cold modalities. 10. Discuss the uses and benefits of hydrotherapy. 11. Describe how an ultrasound treatment works. 12. Describe how to measure a patient for a cane, walker, and crutches. 13. Explain the different crutch gates.
Introduction Orthopedics, also known as orthopaedics, is the branch of medicine that deals with injuries and disorders of the musculoskeletal system and includes the following structures: bones, muscles, joints, tendons, and ligaments. Goals for treatment in this specialty are usually centered on restoring function to the affected area and improving the patient’s quality of life. The orthopedic team usually incorporates a host of specialists who all work together to provide the patient with comprehensive care and the best outcome possible. Medical assistants may work in orthopedic centers and have a variety
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of responsibilities including screening patients, taking vital signs, applying various treatments, and educating patients.
PATIENT SCREENING FOR THE MUSCULOSKELETAL SYSTEM
TYPES OF PROVIDERS WHO SPECIALIZE IN TREATING DISEASES AND DISORDERS OF THE MUSCULOSKELETAL SYSTEM
The bones form the framework for the entire body and serve as points of attachment for muscles, tendons, ligaments, and other connective tissue. There are a multitude of diseases, disorders, and injuries that can affect this system. Medical assistants may have the responsibility of screening patients prior to provider examination. The depth of screening will be established by office protocol, but in general, medical assistants should be able to ask a series of questions related to the patient’s symptoms. Table 21-2 lists types of questions that are typically asked when patients complain of musculoskeletal symptoms and common procedures that coincide with symptoms. Important note: Medical assistants should never perform any procedure unless directed to do so by the provider; however, they can set up various equipment and supplies to help save time in the event that testing is ordered.
An orthopedist is a medical doctor who treats diseases and disorders of the bones and muscles. This specialist treats acute conditions, such as trauma caused by injuries and chronic conditions such as arthritis, in addition to performing surgical procedures including total joint replacement. An orthopedist’s work often overlaps that of the plastic surgeon, gerontologist, pediatrician, chiropractor, or podiatrist. Some orthopedists specialize in treating particular conditions including spinal deformities such as scoliosis (abnormal lateral curvature of the spine) and kyphosis (abnormal forward curvature of the spine), congenital foot disorder, sports injuries, growth plate fractures, joint dysfunction, and the management of complex fractures. Orthopedists often work in conjunction with other specialists and members of the health care team to provide the patient with the best care possible. Table 21-1 lists specialists who work in conjunction with an orthopedist.
ASSISTING WITH THE ORTHOPEDIC EXAM In the orthopedist’s office, the medical assistant’s main duty is assisting with the general exam. Other duties may include ordering x-rays and other diagnostic tests,
TABLE 21-1 Specialists Working with the Orthopedist SPECIALIST
DESCRIPTION/TREATMENT DUTIES
Neurologist
A physician who specializes in diagnosing and treating diseases and disorders of the nervous system, including the brain, spinal cord, and nerves
Neurosurgeon
A physician who specializes in performing surgery on the parts of the nervous system
Physiatrist
A physical medicine doctor who diagnoses and treats neuromuscular and bone diseases and injuries; works closely with the physical therapist
Physical therapist (PT)
A specialist who helps to restore function, improve mobility, and decrease pain to an area that has been damaged by injury or disease
Physical therapy assistant (PTA)
A paraprofessional who assists and works under the supervision of the physical therapist
Occupational therapist (OT)
A medical professional who is responsible for assisting patients with basic motor function, reasoning, and activities of daily living (ADLs)
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TABLE 21-2 Patient Screening and Instructions for the Musculoskeletal System ASK THE PATIENT: “ARE YOU EXPERIENCING ANY. . .”
Injury: Pain or swelling in the affected area, skin discoloration, loss of feeling or tingling? Can you describe the injury? General: Joint pain, swelling, stiffness, weakness? Do you have any history of musculoskeletal disorders?
DISROBING INSTRUCTIONS
Expose affected areas
VITAL SIGNS
All
EQUIPMENT
Casting materials or splints for possible fracture, wrapping materials for possible strain or sprain
POSSIBLE PROCEDURES
X-rays of affected areas, casting or wrapping procedures
COMMON DIAGNOSTIC PROCEDURES PERFORMED ON ORTHOPEDIC PATIENTS The orthopedist uses a variety of examination methods and diagnostic tests to evaluate the structure and function of structures within the musculoskeletal system. Common radiographic studies used in orthopedics can be found in Table 21-3. Other diagnostic tests used include: ❖ Bone/muscle biopsy: Detects bone infection, cancer, and muscle atrophy. ❖ Arthroscopy: A lighted scope is inserted into a joint to inspect the inside of the joint. Surgery
may also be performed using an arthroscope (Figure 21-1). ❖ Electromyography: Needle electrodes are placed into certain skeletal muscles to record and measure nerve impulses. ❖ Urine and blood tests: Measure the amount of minerals in the body such as calcium and phosphorous, which will be increased in the presence of any disorder that involves breakdown of bones or muscles.
STRAINS, SPRAINS, FRACTURES, AND DISLOCATIONS The orthopedist not only deals with the bones, but also treats injuries to the muscles and joints. Patients often seek the care of an orthopedist for injuries such as strains and sprains. A strain is an injury to a muscle or tendon caused by excessive use or overexertion; it is not considered to be as serious as a sprain. Patients with a suspected strain injury should be examined by a provider to
PAT I E N T T U T O R Osteoporosis is a disease that occurs primarily in females. Some of the risk factors include:
❖ Sedentary lifestyle ❖ Smoking
❖ ❖ ❖ ❖ ❖
Treatments include calcium supplementation, regular exercise, estrogen, and other bisphosphonate drugs. Newer medications such as Fosomax® and Boniva® are now being used to treat osteoporosis.
Increasing age (older adult) Early menopause (before age 45) Thin, small frame Family history Low calcium intake
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assisting with casting or cast removal, administering treatment modalities, and patient education regarding home therapies, cast care, and the use of assistive devices. The medical assistant may also be asked to drape, position, or help support the patient during an exam.
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TABLE 21-3 Common Radiographic Studies of the Musculoskeletal System EXAM
DESCRIPTION
USES
CT scan
X-rays that produce cross-sectional views of different areas of the body
To diagnose a variety of diseases and conditions of the bones and muscles
MRI
Uses magnetic waves to produce images of the inside of the body
To visualize any bone, joint, or muscle in the body
Bone scan
Visualizes the distribution of an IV-injected radioactive isotope that collects in the bones and joints
To detect and evaluate areas of arthritis, increases and decreases in bone metabolism, and bone metastases (spread of cancer)
Arthrography
Dye is injected into a joint and x-rays are taken
To view ligaments, tendons, cartilage, and the joint capsule
Discography
Dye is injected into one or more intervertebral discs and a CT scan is performed
Evaluation of discs to determine the cause of pain or the presence of a disorder
X-rays
Permanent film record of a body part
To diagnose fractures and dislocations of the bones and joints of the body
determine the extent of the injury. A strain causes pain upon movement and is usually treated by rest and heat. Occasionally the physician will prescribe a muscle relaxant. A sprain is a more serious injury than a strain. It involves trauma to ligaments and may also involve injury to the tendons and muscles. A sprain may cause swelling and bruising of the affected area, and should
FIGURE 21-1a Inserting an arthroscope
be treated with rest, ice, compression, and elevation (RICE). A dislocation is a temporary displacement of a bone from its usual position in the joint. A dislocation must be returned to its proper position to prevent further injury and damage. Indications of a possible dislocation may include: ❖ ❖ ❖ ❖ ❖
Pain and tenderness Obvious deformity of the joint Swelling Discoloration Loss of function
FIGURE 21-1b An inside view of a joint through an arthroscope
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P ATIEN T TU T OR
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Patients must properly care for a strain or sprain in order for the injury to heal correctly. Recommended home care includes:
Patients who fracture an extremity will often have a great deal of swelling, which is why it is important to inform patients that call the office with a limb injury to apply ice immediately. Cryotherapy, or cold therapy, reduces the patient’s current swelling and helps to prevent further swelling, so that by the time the patient is seen in the office, the swelling should be minimal. If there is a great deal of swelling at the time of the appointment, the provider may be unable to apply a cast and the patient will have to return at a later date to have the cast applied.
❖ ❖ ❖ ❖ ❖
RICE (rest, ice, compression, elevation) Immobilization Anti-inflammatory medications Analgesics Massage
Proper home care will speed the recovery process and help to return the injured part to normal function.
After a dislocation has been reduced, a splint may be used to immobilize the joint to allow for healing. Surgery to correct a dislocation is being performed much more often today, especially in athletes, for once a dislocation occurs, the affected area is much more susceptible to further injury. A fracture or break in a bone can be caused by a pathological condition, injury, or trauma. The main objective of the orthopedist is to realign the bones that are broken to their original position, a process known as reduction. This process promotes healing, decreases
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pain and deformity, and helps the patient regain the use of the injured body part. Unexpected complications such as infection, fat embolisms, or blood clots may arise from fractures. An embolism or a clot can circulate to the lungs, which can be fatal. Fractures are classified as simple/closed or compound/open. In a closed or simple fracture, the bone is broken, but does not penetrate the skin. In an open or compound fracture, the broken bone protrudes through the skin, resulting in an open wound. When the bone penetrates the skin, there is also the danger of severing a vein or an artery, which may cause a lifethreatening hemorrhage.
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Medical assistants often have the responsibility of providing home care instructions to patients with limb injuries. When using EMR, all the medical assistant has to do is click on the appropriate tab (patient education, home care instructions, etc.) and select the instructions that best correlate with the patient’s injury (sprain management, cast care, etc.). The medical assistant will then have the option to either review the information with the patient from the computer screen at the point-of-care, or to print the material directly from the screen and review it with the patient after printing. The medical assistant can even ask if the patient would like to have the information e-mailed to the patient’s personal e-mail address.
C R I T I C A L T H I N K I NG CHALLENGE You are rooming a patient who is complaining of an injury to the ankle. The patient fell down the stairs and is having trouble putting weight on the leg. After you unwrap the ankle, you discover that it is swollen, bruised, and misshapen. You suspect a fracture. You received your general machine operator’s license so you are able to perform x-rays in your office. 1. Should you go ahead and perform an x-ray and have it ready for the provider to save time? 2. Why or why not?
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Fractures are treated differently from strains, sprains, or dislocations. Fractures must be reduced as soon as possible, which involves placing the broken bone fragments back into their original position. Two types of reductions may be used: ❖ Closed reduction: The bone is realigned or “set” without making an incision into the skin. ❖ Open reduction: An incision is made into the skin to realign the bones. The orthopedist will sometimes use screws, rods, and plates to hold the bones in place. Table 21-4 lists information on the different types of fractures, and Figure 21-2 illustrates the various types of fractures. Once a fracture has been reduced, a cast or other immobilization device is applied to the affected body part. Splints or casts support and protect the broken bone during the healing process.
Casts A cast is composed of a hard plaster or fiberglass layer placed over a soft cotton layer. The cast usually extends to the joints above and below the fractures. Half casts are sometimes used to allow for swelling; however, they offer less support than a full cast. Most casts are made of either plaster or fiberglass (Figure 21-3). Plaster is cheaper and shapes better, but fiberglass is lightweight, long lasting, and breathable. Casting materials (Figure 21-4) usually come in rolls that are dipped in water and then applied over a layer of cotton or synthetic padding. The material is smoothed and shaped during application so it will hold the bone in the correct position after it hardens.
Other Immobilization Devices In particular conditions, a cast is not necessary and other immobilization devices are used.
TABLE 21-4 Types of Fractures TYPE OF FRACTURE
DESCRIPTION
Complete
The bone is completely broken into two or more pieces.
Incomplete
The bone is partially broken.
Complicated
A bone is broken and surrounding tissue is also damaged.
Greenstick
The bone is partially bent and partially broken (often seen in children).
Compression
A piece of the broken bone is driven inward. Sometimes seen in skull fractures.
Hairline
A crack in a bone that can be seen on an x-ray. The bone ends are perfectly aligned and the break does not go all the way through the bone.
Impacted
A break in which one bone fragment is wedged into the other bone fragment.
Pathological
A fracture due to a disease condition such as osteoporosis.
Pott’s
A fracture that occurs at the distal end of the tibia or fibula just above the ankle.
Spiral
A fracture that occurs as a result of twisting the bone. The fracture spirals around a long bone.
Stress
A fine hairline fracture that occurs as a result of repetitive traumas due to running, aerobics, or marching. Difficult to diagnose by x-ray.
Colles
A fracture of the distal end of the radius bone in the wrist.
Comminuted
The bone is broken or splintered into fragments.
Transverse
The bone is fractured at a right angle to the axis of the bone.
Oblique
A diagonal fracture of a bone.
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Transverse Oblique
Greenstick (incomplete)
Closed (simple, complete)
Open (compound)
Comminuted
Impacted
Spiral
Colles
FIGURE 21-2 Examples of different types of Depressed
fractures
A splint is a stiff device used to support and immobilize a part of the body that has been injured or fractured. Figure 21-5 illustrates one type of removable finger splint. A splint typically consists of an inflexible material, like plastic, fiberglass, or metal and may come with Velcro straps (Figure 21-6) to hold it in place. Orthopedists can also make a custom splint
of plaster or fiberglass for a better fit. Splints may be used before a cast is applied to allow for swelling. Once the swelling has decreased, a cast can then be applied. Traction can also be used to immobilize a body part by attaching a weight to pull or draw the bones into proper alignment.
FIGURE 21-3 An example of a Fiberglass cast
FIGURE 21-4 Various casting materials
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F IEL D S M A R T S While the provider will usually apply the cast, your role may include: ❖ Setting up the required equipment and supplies ❖ Assisting the provider as needed ❖ Educating the patient on proper care of the cast ❖ Alerting the patient to signs of complications that should be reported to the provider immediately
FIGURE 21-5 One type of splint to immobilize a finger
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CR ITI C A L TH I N K I N G C H AL LEN G E (Refer to the Patient Tutor tool box below to answer this challenge.) A patient calls the office to report burning and stinging underneath the cast on his arm. The patient also reports that there is a funny smell coming from the inside of the cast. 1. What could be causing these problems? 2. Should the patient be given an appointment right away?
FIGURE 21-6 An arm splint with Velcro fasteners
The following are guidelines that will help to ensure proper healing of the fractured bone and improve the longevity of the cast:
❖ Do not pull on the padding inside the cast. ❖ Do not stick objects inside the cast. ❖ Do not trim the edges of the cast.
❖ Allow the cast material to dry completely. ❖ The casted extremity should be elevated to reduce swelling (swelling during the first 48 to 72 hours may cause pressure and tightness). ❖ Move toes or fingers often and check for a color or temperature change. ❖ Apply an ice bag to the cast over the area of the break. ❖ Keep the cast dry. ❖ Cover the cast with a protective waterproof covering when bathing.
Report the following symptoms to the provider immediately: ❖ Increased pain, numbness, or tingling ❖ Excessive swelling ❖ Cold fingers or toes or loss of movement (could indicate that the cast is too tight) ❖ Burning or stinging (could also indicate that the cast is too tight) ❖ Foul odor coming from inside the cast (could mean infection)
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An external fixation device, such as a “halo” (Figure 21-7), may be placed on the head to hold the neck rigid during healing. Rods placed on the outside of a limb and held in place by pins that pierce the skin can hold the bones of an extremity in place until healed. Other immobilization devices include equalizer walking boots, which allow for greater mobility during healing, and stabilizing support braces for the wrist, ankle, and knee.
ALTERNATIVE TREATMENT METHODS Fractures and other injuries may be serious enough that realignment and immobilization are not enough to ensure proper healing. Often, the orthopedist must perform surgery and place screws, wires, pins, and plates to repair and realign the damaged bones. In some instances, the pins and wires can be removed once the healing process has taken place.
Orthopedic Surgical Procedures Advances in medical science have given the orthopedist the skills, tools, and materials to not only repair badly broken bones, but to reconstruct and even replace damaged parts of the skeleton. Hands can now be reconstructed, the spinal vertebrae can be fused together, and whole joints can be replaced.
FIGURE 21-7 An example of a “halo” immobilization device
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Joint replacement surgery has become a treatment option for patients with severe arthritic conditions. A joint may also be replaced to repair a previous injury or to correct a deformity. Knees, hips, and shoulders can now be surgically restored by removing certain damaged parts of the joint and substituting them with a plastic or metal device called a prosthesis (artificial joint). Patients may be considered candidates for joint replacement if they have: ❖ Limited function and mobility affecting work, recreation, and activities of daily living (ADLs). ❖ Pain that has not been relieved by medications, physical therapy, arthroscopy, using a cane, or restricting activity ❖ Significant joint stiffness ❖ X-rays revealing advanced arthritis or other issues
Treatment Options for Arthritis Another option available to help relieve the severe pain associated with osteoarthritis of the knee is viscosupplementation treatment. This type of treatment consists of injecting a preparation of hyaluronic acid—made from rooster combs or bacterial cultures—directly into the knee joint. This lubricates the joint and keeps the dry bone ends from rubbing together, which causes intense pain. The injections are administered in three doses given one week apart. Patients should be informed that they will not feel the full effects of the treatment until approximately one month after the last injection. Some patients do very well with this treatment, resulting in a delay of surgery as long as the treatment proves to be beneficial, while others experience little or no relief at all. New techniques are being developed to restore cartilage in joints where it has been lost. Cartilage grafting involves transplanting cartilage from a healthy area into the joint that has little or no cartilage left. A patient’s own tissue (autograft) or a donor graft (allograft) may be used. To prevent rejection of the grafted tissue, however, a tissue match must be found. Another technique used to replace lost cartilage is stem cell regeneration. Stem cells are harvested through bone marrow aspiration (the withdrawing bone marrow) and under the right circumstances can regenerate articular cartilage. This technique is still being developed, but shows a lot of promise in treating particular injuries and arthritis.
REHABILITATION Part of the healing process following an injury or orthopedic surgery involves rehabilitation and physical therapy. The goal of this type of treatment is to restore
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PA TIEN T P E R SP E C T I V E I overheard you talking to the other medical assistant about me. You said that my hair was really dirty and that I had really bad body odor. Ever since I broke my right arm (I’m right-handed) I have not been able to shower or wash my hair properly and I have no one to help me. I wish you would refer me to an agency that could assist me rather than making unkind comments about me to your coworkers.
as much function and mobility to the patient as possible. For some patients who suffer a permanent loss of function, rehabilitation helps them find a workable solution to assist them with the activities of daily living (ADLs). Many health care professionals play an important role in a patient’s recovery.
Physical Therapists and Occupational Therapists Physical therapists (PTs) and occupational therapists (OTs) are medical specialists that use a variety of treatment methods to help patients recover from injury or surgery and also to cope with chronic illnesses and conditions. The goals of the PT and OT are to: ❖ Reduce the extent of damage to an injured or diseased limb or other related structure. ❖ Assist in recovering lost function ❖ Aid the patient in adjusting to the current level of activity
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F IEL D S M A R T S Your role in physical therapy may be to administer a variety of modalities including thermotherapy, hydrotherapy, and ultrasound treatments. The provider will prescribe the exact treatment necessary and you will follow the provider’s instructions. Remember: Never administer any type of treatment without a direct order from the provider.
❖ Help the patient to remain fit ❖ Assist the patient in performing ADLs with little or no help from others The OT assists patients with learning how to perform ADLs with the least amount of strain on the impaired body part. The OT can also make suggestions for modifying the home or workplace and even recommend assistive devices to help with bathing, driving, dressing, and housekeeping. The PT utilizes physical agents or modalities such as heat, cold, water, massage, and exercise to improve or restore lost function. The PT may also suggest the use of an assistive device like a cane, a walker, or crutches to help the patient with mobility.
Thermal Modalities Thermal modalities include the use of heat (thermotherapy), cold (cryotherapy), and deep heat therapy achieved through the use of ultrasound. The following factors should be considered before applying any hot or cold modality: ❖ The age of the patient should be considered. Infants and the elderly are more sensitive to heat and cold and may be unable to report painful sensations. ❖ Use caution when administering treatment to particularly sensitive areas. ❖ Avoid areas with broken skin. ❖ Patients with impaired circulation or sensation, such as those with diabetes or cardiovascular disease, may be unable to distinguish the degree of heat or cold. ❖ Do not apply heat during the first 24 hours of an acute injury or when edema or inflammation is present. ❖ Always wrap hot or cold articles in a cloth before applying them to the skin.
Thermotherapy Thermotherapy entails applying dry or moist heat to a body part to promote healing and restore function. Heat increases circulation by creating vasodilation (expansion of blood vessels). Increased circulation accelerates tissue metabolism, which promotes healing. Heat is used to: ❖ ❖ ❖ ❖ ❖
Relax muscles and alleviate muscle spasms Relieve pain Increase flexibility Provide comfort Promote drainage from an infected area
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Heat therapy is categorized as dry or moist. Dry heat modalities include: ❖ Heating pads: Always cover the pad with a cloth or towel and adjust the temperature to the level prescribed by the provider. Do not adjust the temperature to a higher level if requested by the patient, as this could result in a severe burn. ❖ Hot packs: Chemical hot packs (Figure 21-8) become hot when activated by following the manufacturer’s directions. These disposable, flexible packs easily adjust to fit different body parts. ❖ Hot water bottles: The water temperature should not exceed 110ºF (43ºC). After filling, cover with a cloth before applying to the body. Refill as needed to maintain the proper temperature level.
FIGURE 21-9a Continually dip hot compresses into basin of hot water to keep them warm.
Moist heat modalities penetrate better than dry heat modalities and include the following: ❖ Hot compresses (Figure 21-9): A gauze pad or soft cloth is soaked in water no hotter than 110ºF (43ºC), wrung out, and applied gradually over the affected area. This modality can easily be administered at home. ❖ Hot packs: The pack is soaked in hot water no greater 110ºF (43ºC), covered with a pad, and placed on larger areas of the body, such as the back and shoulders. ❖ Hot soaks: The body part is immersed in plain or medicated water that is no hotter than 110ºF (43ºC) for approximately 15 minutes. This treatment is usually used for the extremities. ❖ Paraffin baths: Used to treat chronic joint diseases, like rheumatoid arthritis. The affected body part is dipped into a mixture of melted paraffin and water until a thick coating of wax is achieved. After 30 minutes, the paraffin is peeled away. FIGURE 21-8 Examples of chemical heat and cold packs
FIGURE 21-9b Carefully apply moist hot compresses directly to the affected area. Note: Once the compress is applied to the skin, wrap a waterproof drape around the area to keep the warmth in.
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C R I T I C A L T H I N K I NG CHALLENGE The provider has asked you to apply a heat treatment to a patient’s shoulder. You are to use a heating pad on the low setting for 20 minutes. After five minutes of treatment, the patient complains that the heat is too low to be felt and asks you to turn the setting to high. 1. What would you tell the patient? 2. What could happen as a result of the adjustment? 3. Should the provider be informed of the patient’s request?
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Refer to Procedure 21-1 for instructions on applying different heat modalities.
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Cryotherapy Cryotherapy involves the application of dry or moist cold to the affected area of the body. Application of cold constricts the blood vessels and induces contraction of the involuntary muscles. Cold application can also produce a numbing affect, which can help to reduce pain. Indications for cryotherapy include: ❖ Prevents swelling by decreasing the accumulation of fluid in the tissue ❖ Pain relief ❖ Decreases inflammation ❖ Decreases pus formation by suppressing microbial growth ❖ Decreases body temperature ❖ Helps to control bleeding Cryotherapy is most effective if used frequently during the first 48 hours after an injury. Dry cold modalities include: ❖ Ice bags: The bag should be covered with a cloth before applying it to the body and can be left on the area for approximately 20 to 30 minutes. ❖ Commercial ice packs: This type of pack is filled with materials that can be chilled in the freezer. Commercial ice packs usually contain a type of gel that does not freeze into a solid, which makes the pack more flexible and able to easily conform to any body part. This pack should be left in place according to the manufacturer’s directions. ❖ Chemical ice packs (Figure 21-10): These packs must be activated by squeezing or shaking the contents. The pack will stay cold for approximately 30 to 60 minutes. Moist cold modalities are usually used for smaller areas of the body and include: ❖ Cold compresses: These are created by dipping a cloth or gauze into ice water, which is then applied FIGURE 21-10 A chemical ice pack. to the affected area. The These types of packs cloth must be remoistened should be covered frequently throughout the with a cloth before applying to the skin. treatment to maintain the proper temperature. ❖ Ice massages: This modality is used following physical therapy, and consists of massaging the
If the patient does not have a commercial ice pack available, a bag of frozen vegetables will work as a cold pack. As the bag thaws a bit, it contours around the patient’s limb. Instruct the patient to lay a towel or cloth between the skin and the frozen vegetables.
body area with a large ice cube, created by freezing water in a paper cup. Procedure 21-2 provides instructions on administering treatments with cold modalities.
Ultrasound A deep-tissue modality such as therapeutic ultrasound is used to promote healing of deeper tissues. Ultrasound uses high frequency sound waves to create heat deep in soft tissues like muscles and tendons. Ultrasound works best on tissues with a high water concentration and does not penetrate the bone at all. The medical assistant may be trained to administer an ultrasound treatment in the provider’s office under the direction of the provider; however, the laws governing medical assisting duties can vary by state, and it is a good idea to check the Medical Practice Act in the state where you are employed. The treatment involves the use of an ultrasound machine and a coupling agent. The machine consists of two main parts: the generator, which is the main component that contains the controls, and the transducer, the part that comes into direct contact with the FIGURE 21-11 Metron Vectorsonic VU270 ultrasound unit (Courtesy of Med 1 Online.)
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P ATIEN T TU T OR Inform the patient that the ultrasound waves should not be felt during the treatment, and that the patient should report any uncomfortable sensation immediately. Explain to the patient that the full effects may not be felt for several days following the treatment.
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F IEL D S M A R T S If the patient reports any pain or discomfort during an ultrasound treatment, stop the procedure immediately and consult the provider.
patient’s skin. Refer to Figure 21-11 for an example of an ultrasound unit. A coupling agent, such as a gel, is applied to the patient’s skin for better conduction of the sound waves. The head of the transducer is continuously moved in a circular motion over the affected body part. Continuous movement prevents the sound waves from being concentrated in one area, which could result in burns and tissue damage. A treatment usually lasts from 5 to 15 minutes and should not exceed 20 minutes.
Hydrotherapy This type of therapy, which uses circulating water, is usually performed in hospitals and large clinics, but may also be used in orthopedic and podiatry offices. Hydrotherapy is used to treat injuries, burns, and other physical problems. Forms of hydrotherapy include: ❖ Whirlpools: This therapy consists of a tank filled with constantly moving water. Pressurized air shoots from jets located in the walls of the tank that keep the water circulating. The moving water creates a gentle massage, which increases circulation and relaxes muscles. Whirlpools may range in size from small models that will house one body part, to those large enough to immerse the entire body. This type of treatment is also used to remove necrotic tissue from burn patients, through a process known as debridement. ❖ Contrast baths: This method is most often used to treat the hands and feet. The hand or foot is first
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immersed in hot water for 1 minute and then cold water for 30 seconds. The process is repeated for the prescribed amount of time. The contrast bath should end with cold immersion. This type of hydrotherapy promotes circulation and relaxation. ❖ Medicated baths: The body is soaked in a bath to which a substance such as oatmeal or Epsom salts has been added. ❖ Water exercises: Exercises are performed in a warm swimming pool, in water that is shoulder-deep. Exercising in water relieves pain and relaxes muscles and is ideal for patients with joint problems. The water supports the body and makes movement more tolerable by taking pressure off the joints.
Exercise Therapeutic exercise may be prescribed as a treatment for arthritis and fractures, to promote healing and flexibility following an injury, surgery, amputation, and even for patients who have suffered a stroke. Most exercise programs are designed by the provider to accommodate each patient’s individual needs. Therapeutic exercise is used for a variety of reasons including: ❖ Helping a patient to regain mobility after an accident, injury, or surgery ❖ Preventing muscle atrophy during a prolonged period of immobilization ❖ Developing or improving neuromuscular coordination ❖ Developing muscle tone and strength ❖ Improving circulation ❖ Strengthening the heart and lungs Table 21-5 lists some of the different types of exercises commonly prescribed. Figure 21-12 illustrates
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PATIENT TUTOR Once the provider prescribes an exercise program, you may be asked to demonstrate and illustrate the exercises. Written instructions should also be given to the patient and caregiver. Stress the importance of being compliant and make sure the patient can do the exercises before the patient leaves the office. Teach the caregiver or family member how to perform the exercises and how to supervise the patient while the patient is performing them.
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TABLE 21-5 Forms of Strengthening Exercises TYPE
DESCRIPTION
USES
REQUIRED EQUIPMENT
Active
Performed by the patient without assistance
Increases muscle strength and function
Treadmill Stationary bike
Passive
Physical therapist moves the body part without any voluntary movement by the patient
Treats neuromuscular problems, helps to maintain range-of-motion, and increases circulation
Machines designed specifically to assist with different body movements
Assisted
Self-directed, aided mobility
Improves muscle strength
Walking in a swimming pool
Active resistance
Voluntary movement by the patient against pressure created by the physical therapist or a machine
Increases muscle strength
Refer to equipment for passive exercises
Range of motion (ROM)
Gentle movement of a joint through its normal range of motion
Relieves stiffness, improves joint movement, and increases flexibility Recommended to treat joint injuries and the elderly
None needed
FIGURE 21-12 Examples of range of motion (ROM) exercises and movements, which are performed to improve circulation, flexibility, and muscle tone Spine
Elbow
Flexion Pronation
Cervical Lateral flexion
Rotation
Flexion, extension, hyperextension
Supination
Extension
Knee Extension
Flexion Wrist
Trunk Lateral flexion
Rotation
Flexion, extension, hyperextension
Shoulder Abduction
Adduction Hip Abduction
Adduction
Ankle
Flexion
Dorsiflexion
Extension
Ulnar Radial Hyperextension Plantarflexion flexion flexion Eversion Inversion (adduction) (abduction)
Rotation: outward, inward
Fingers Adduction
Toes Adduction
Extension
Abduction
Flexion
Flexion, extension, hyperextension
Rotation: outward, inward
Abduction
Flexion, extension, hyperextension
Flexion Extension
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some of the ROM exercises, and Table 21-6 lists the terms used to describe the different forms of movement used in ROM.
Electrical Stimulation of Muscles Injured muscles and muscles that have not functioned for a prolonged period of time may need to be stimulated in order for the patient to be able to move. Lowvoltage electric current is delivered directly into a muscle, which causes it to involuntarily contract and relax. This helps to prevent muscle atrophy and stimulates healing. A transcutaneous electrical nerve stimulation (TENS) unit can be worn by patients with spinal cord injuries to help them ambulate and can also be worn to aid in pain control.
AMBULATORY ASSISTIVE DEVICES The term ambulation means the ability to walk or move about freely. Following an injury, surgery, or prolonged illness, it may be necessary for a patient to use an assistive device in order to ambulate, such as a cane, crutches, walker, or wheelchair. The specific type of assistive device prescribed by the provider will depend upon the amount of support needed by the patient. The age of the patient and the
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amount of muscle strength will also be considered before deciding on the proper device.
Canes A cane will usually be prescribed for the patient who needs slight support on one side of the body. Canes are generally used long term, especially for patients with a weakness on one side of the body due to a stroke or those with poor balance. Canes are usually made of wood or metal and have either a curved or T-shaped handle (Figure 21-13). Basic types of canes include: ❖ Standard: Used for patients needing little support. ❖ Tripod: Three-legged base, which provides greater stability than a standard cane. ❖ Quad: Rests on four legs and also provides a greater amount of support and stability than other types of canes. Both the tripod and quad canes are adjustable, have T-shaped handles, and can stand alone, which allows the patient to use both arms when standing from a sitting position. Canes must be the correct height in order to provide optimum support for the patient. When the patient stands tall and places the hand on the handle of the cane it should be even with the top of the hipbone, and the elbow should be flexed at a 20º to 30º angle.
TABLE 21-6 Joint Movement Terms TECHNICAL TERM
DESCRIPTION
Abduction
Movement away from the midline of the body
Adduction
Movement toward the midline of the body
Circumduction
To move a body part in a circular motion
Dorsiflexion
Posterior movement of a body part at the joint
Eversion
Turning outward
Extension
To straighten; the opposite of flexion
Flexion
To bend; the opposite of extension
Hyperextension
Abnormal or extreme extension (beyond normal limits)
Inversion
To turn inward
Plantar flexion
Pointing the foot downward at the ankle
Pronation
Turning the palm downward; lying face down
Rotation
Turning a body part on its axis
Supination
Turning the palm upward; lying flat on the back
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FIGURE 21-13 Various types of canes that work with the patient’s mobility level
The patient should not lean on the cane, but use it as a support for better ambulation and balance. The cane is held in the hand on the strong side of the body. The medical assistant may be asked to instruct the patient on the proper use of a cane or to reinforce the instructions given by the provider. Refer to Procedure 21-3 for instructions on the use of a cane.
FIGURE 21-14 A platform crutch, Forearm/Lofstrand crutches, Axillary crutches
types of crutches are pictured in Figure 21-14: platform, forearm, and axillary crutches. Axillary crutches, usually used during healing of a lower extremity, have a shoulder rest and a handgrip and extend from the floor to just beneath the armpit. Figure 21-15a shows a patient using axillary crutches. The forearm or Lofstrand/Canadian crutch extends from the ground to the forearm. A plastic or metal cuff is attached to the crutch, which wraps around the patient’s forearm. With this type of crutch, the weight is borne on the handgrip, which is protected by rubber. This crutch type requires greater strength and coordi-
Crutches Crutches are usually used when weight bearing on the foot or leg is prohibited. Patients recovering from a sprain or fracture and those with certain diseases or congenital deformities may be required to use crutches in order to ambulate. Crutches are made from wood or aluminum with rubber tips to prevent slippage on the floor. Three FIGURE 21-15 A patient demonstrating the use of different types of crutches: (a) axillary, (b) forearm/Lofstrand, and (c) platform
(a)
(b)
(c)
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nation and is usually used long term by patients with cerebral palsy or paraplegia (Figure 21-15b). Platform crutches are designed for use by patients who cannot bear weight on their hands or wrists or who have difficulty gripping the handles. A platform with a handgrip is attached to the top of the crutch and is designed so that the patient bears weight on the entire forearm (Figure 21-15c).
Measuring for Axillary Crutches Axillary crutches must be properly fitted to each individual patient. Improperly fitting crutches can cause nerve damage and injuries to the axilla and palms of the hands. Crutches that are too long can create pressure in the armpits and force the patient’s shoulders forward, which can cause back strain and make walking difficult. Crutches that are too short cause the patient to bend forward when walking, which causes poor balance. To determine the correct crutch height, the patient should be instructed to stand erect. The crutch tips should be placed two inches in front of and four to six inches to the side of each foot. Adjust the crutch length so that the axillary bar is two to three fingerwidths below the axilla (Figure 21-16). The handgrips should be adjusted so that the elbows are bent at an angle of approximately 20° to 30°.
Crutch Gaits Generally, there are five crutch gaits used: two-point, three-point, four-point, swing-to, and swing-through. The gait used depends on the amount of weight bearing FIGURE 21-16 Correctly measure the patient for axillary crutches by adjusting them so that the crutches are two or three fingerwidths below the patient’s armpits.
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PATIENT TUTOR Caution patients to bear their weight on the hands and not the armpits. Bearing weight on the axilla can cause permanent nerve damage, as well as soreness, which can cause muscle weakness in the hands, wrists, and forearms.
allowed and the patient’s physical condition. Table 21-7 lists an explanation of the different gaits. When describing a gait, the term “point” refers to when the patient’s foot or the crutch touches the ground. Procedure 19-4 lists the steps necessary to instruct patients in the different gaits. Figure 21-17 illustrates the different crutch gaits.
Walkers A walker provides the most support and stability for those patients with balance and coordination difficulties. Walkers are often used by geriatric patients and those who are recovering from knee and hip replacement. Walkers are made of an aluminum frame with four legs and handgrips and are open on one side (Figure 21-18). They can be folded for easy storage. The height of the walker may be adjusted by having the patient stand on a level surface. The top of the walker should be level with the patient’s hip joint. Walkers are available with rubber tips on the legs (stationary) or with wheels attached to the legs (rolling), which allows for faster ambulation. While walkers provide maximum support and stability, they are sometimes bulky and difficult to maneuver in small areas. A physical therapist usually fits the patient for a walker and provides training in its use; however, the medical assistant may be asked to teach the patient to use a walker (refer to Procedure 21-5).
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FI E L D S M A R T S When helping patients with assistive devices, consider using a gait belt. If the patient loses balance, all you will have to do is lift up on the gait belt. This helps to prevent the patient from sustaining an injury due to a fall.
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TABLE 21-7 Crutch Gaits GAIT
DESCRIPTION
USES
Four-point
Basic and slow gait, which allows the patient to bear weight on both legs. Provides three points of support at all times, very stable and safe.
Patients with muscle weakness in the legs, poor balance or coordination, and degenerative diseases.
Three-point
The patient must support the weight on only one leg. Both the crutches and the weak leg are moved forward at the same time. The weight is then transferred to the crutches and the strong leg is moved forward.
Amputees without prostheses; patients with lower extremity trauma, fractures, and sprains; and patients recovering from surgery.
Two-point
Two points support the body at the same time. More advanced gait, used after mastery of the four-point gait.
Partial weight bearing on both legs in patients with good muscle coordination.
Swing-to
The crutches are moved forward simultaneously and the weight is transferred forward. Both feet are then moved forward together, ending even with the crutches.
Patients suffering from paralysis or severe disabilities of the lower extremities, patients wearing leg braces.
Swing-through
The crutches are moved forward simultaneously while transferring the weight forward. Both feet are then moved forward together, ending slightly in front of the crutches.
Same as swing-to.
1
2
FIGURE 21-17 Examples of crutch gaits: (a) two-point,
3
(b) three-point, and (c) four-point
(a) 1
(b)
2
3
4
1
(c)
2
3
4
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FI E L D S M A R T S Smart medical assistants will familiarize themselves with the parts of the wheelchair prior to working with patients. Know how to lock the wheels, how to remove and apply the foot pedals, and how to collapse the wheelchair just in case you have to park it out of the way during an x-ray or examination. Always use a gait belt for wheelchair transfers and remember to bend your knees, not your back, when lifting patients to avoid injuring yourself.
FIGURE 21-18 A stationary walker
Wheelchairs Wheelchairs are devices that enable a patient who would otherwise be immobile to move about. Chairs can be of the portable-foldable type or large motorized models. Figure 21-19 illustrates two of the many
types of wheelchairs available. There are now models specially designed to allow patients to participate in sporting events. Based on the patient’s needs and disabilities, the physical therapist will determine the appropriate type of chair. Patients may come to the office in a wheelchair to be seen by the provider and often will need to be assisted onto the exam table in order for the provider to complete the exam. Procedure 21-6 lists the steps for transferring a patient from a wheelchair to the exam table and back to the chair again.
FIGURE 21-19 Two types of wheelchairs: (a) manual and (b) motorized
(a)
(b)
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PROCEDURE 21-1 Administer Heat Therapy Treatments Objective: To correctly apply heat modalities to different areas of the body as prescribed by the provider.
Equipment/Supplies: ❖ Basin ❖ Plain warm water or soaking solution, if ordered by the provider ❖ Thermometer ❖ Gauze PROCEDURAL STEPS
❖ ❖ ❖ ❖ ❖
Washcloths Towels Heating pad with protective cover Hot water bottle Patient’s record
RATIONALE
1. Assemble the supplies and wash your hands.
Hands must be washed before each patient contact.
2. Identify the patient using two identifiers, identify yourself, and explain the procedure.
Patients should understand the process before the treatment is started.
3. Instruct the patient to remove clothing and put on a gown, if necessary, exposing the area to be treated.
The patient’s modesty should be protected.
4. Place the patient in the proper position for the treatment.
The body part being treated must be easily accessible and the patient should be in a comfortable position during the treatment.
5. Administer heat therapy as ordered: Heating pad: a. Place the protective covering over the heating pad. b. Connect the cord to an electrical outlet and set the control to the setting indicated by the provider. c. Place the heating pad on the affected area (do not allow the patient to lie on the heating pad) and ask the patient how the temperature level feels. Hot water bottle: a. Fill the hot water bottle approximately half full with water [the water temperature should be between 105°F and 110ºF (40.5°C and 43ºC)]. b. Compress the air out of the bottle and close the lid tightly. c. Cover the water bottle with a cloth or towel. d. Leave in place for the prescribed amount of time. Hot Compress: a. Fill a basin with hot water [between 105°F and 110ºF (40.5°C and 43ºC)]. b. Soak cloth or gauze in hot water and wring out excess moisture. c. Place the compress over the affected area. Cover the compress with a plastic covering.
The pad must be covered to protect the patient’s skin and to absorb perspiration. The setting is usually low or medium.
Instruct the patient not to adjust the temperature to a higher level, as this could result in an injury or burn.
The provider will indicate the correct temperature of the water to be used, which will depend on the body area being treated. Leakage of the hot water could cause a burn. Placing the surface of the hot water bottle directly on the patient’s skin could result in damage or a burn. Prolonged treatment may result in tissue damage to the area. The water must be the correct temperature to be effective and decrease possibility of damage to the skin. The compress should be wet, but not dripping. Covering the pack with plastic helps to maintain the temperature.
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PROCEDURAL STEPS d. Re-wet the compress to maintain the correct temperature. e. Replace the compress every few minutes for the amount of time prescribed by the provider. Hot Pack: a. Hot packs are soaked in hot water, allowed to drain, and covered with a pad. They are used on larger areas of the body, such as the back or shoulder (Figure 21-20). Hot Soak: a. Fill an appropriate-sized container with hot water [approximately 105–110ºF (40.5–43°C)] and add medication to the water if ordered by the provider. b. Place the body part in the water for the prescribed amount of time. c. After the prescribed amount of time, remove the body part from the soak and dry with a towel. Inspect the area for any redness or damage. Paraffin Bath: a. A paraffin bath, composed of water and mineral oil, should be heated to approximately 127ºF (53ºC). b. Dip the affected body part in the paraffin until a thick coating of wax builds up. c. Wrap the body part in foil, plastic wrap, or a cloth for 30 minutes. d. Take the covering off and peel away the wax.
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RATIONALE A compress that is not the correct temperature will not be as effective. The provider will determine the amount of time the treatment should be administered.
Check the temperature of the water with a thermometer to ensure accuracy. The provider’s orders should always be followed. The part should be inspected for any signs of damage following the treatment.
FIGURE 21-20 Applying a commercial heat pack to the patient’s shoulder (gloves are optional)
The paraffin must be completely melted before beginning the treatment. A thick coat will hold the temperature for a longer period of time. The paraffin must be left on for prescribed amount of time to gain the desired effect of the treatment.
6. Check with the patient periodically during any heat treatment. The patient may feel chilled during the treatment, so cover the patient with a sheet or blanket.
Applying heat to the body dilates the blood vessels, which causes heat loss and can produce a chilled feeling.
7. Check the treatment area for signs of damage such as redness, blisters, or irritation.
If any signs of problems are observed, stop the treatment and inform the provider.
8. Assist the patient with dressing, if needed. 9. Clean the area and wash hands. 10. Document treatment in the patient’s chart.
Hands must be washed after each patient. Every procedure must be documented in the patient’s chart.
DOCUMENTATION EXAMPLE:
08-12-XX 1:30 p.m.
Hot compress applied to right forearm x 10 minutes per Dr. Cho’s orders. No blistering or redness observed after treatment. Pt. tolerated procedure well. Ryan Leonard, CMA (AAMA)
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PROCEDURE 21-2 Administer Cold Therapy Treatments Objective: To correctly administer cold modalities to different areas of the body, as prescribed by the provider.
Equipment/Supplies: ❖ ❖ ❖ ❖ ❖
Basin Water Ice cubes Gauze Washcloths
PROCEDURAL STEPS
❖ ❖ ❖ ❖ ❖
Ice bag Commercial cold pack Chemical cold pack Large ice cube frozen in a paper cup Patient’s record
RATIONALE
1. Assemble the supplies and wash your hands.
Hands must be washed before each patient contact.
2. Identify the patient using two identifiers, identify yourself, and explain the procedure.
Patients should understand the process before the treatment is started.
3. Instruct the patient to remove clothing and put on a gown, if necessary, exposing the area to be treated.
The patient’s modesty should be protected.
4. Place the patient in the proper position for treatment.
The body part being treated must be easily accessible and the patient should be in a comfortable position during the treatment.
5. Administer the cold therapy as ordered: Ice Bag: a. Check the ice bag for damage or leaks. b. Fill the bag approximately two-thirds full with small ice chips or cubes; refill as needed (Figure 21-21). c. Squeeze the bag to expel excess air and screw the top into place.
d. Cover the pack with a towel for patient comfort and to help absorb any moisture. e. Keep the ice bag in place for the amount of time ordered by the provider (usually 15 to 30 minutes). Commercial Ice Pack: a. Place the gel pack in the freezer for the amount of time recommended by the manufacturer. b. If pack has a protective covering over it, place it on the affected area. c. If there is no covering on the pack, cover the pack with a cloth or towel before applying. d. Leave the pack in place for the prescribed amount of time.
A leaky bag can cause the patient to become wet and chilled. Small ice chips help the bag to conform to the body part better. Air in the bag can create spaces, which will not allow for good conduction of the cold and can also cause the bag not to conform easily to the body part. Covering the pack helps to keep the area from becoming too cold. The area should feel numb, but there should not be pain or extreme paleness.
FIGURE 21-21 The medical assistant fills an ice bag with ice cubes (gloves are optional).
This ensures that the pack is completely cooled and will retain the correct temperature for the amount of time indicated. Placing a cold pack directly on the patient’s skin could cause damage.
Exceeding the prescribed amount of time could result in damage to the area.
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e. Place the bag in the freezer after use. Chemical Ice Pack: a. Inspect the bag for leaks. b. Squeeze the bag and shake.
The bag must be cooled before using again.
c. Cover the pack with a protective covering. d. Apply the pack to the affected area for the amount of time prescribed by the provider. e. Discard the pack after use. Cold Compress: a. Place a small volume of water in a basin, and add large ice cubes to the water. b. Soak a washcloth or gauze pad in the water and wring out any excess. c. Place an ice pack over the compress. d. Re-wet, as needed, to maintain the temperature of the compress. e. Repeat application every 2 to 3 minutes for the amount of time prescribed by the provider. Ice Massage: a. Fill a paper cup three-fourths full of water and place in the freezer. b. Expose the area to be treated and squeeze the paper cup so the ice cube is exposed. c. Move the ice cube in a circular motion over the affected area for the prescribed amount of time, or until the patient reports numbness and burning in the area. 6. Check the treatment area following the procedure for paleness, redness, blueness, or any other signs of damage.
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Leaking chemicals can cause damage to the skin. Squeezing and shaking activates the pack so it becomes cold. Covering protects the skin in the area being treated.
Chemical cold packs are for single use only. Large ice cubes melt more slowly and will maintain the cold temperature of the water for a longer period of time. Excess cold water can drip on the patient and cause the patient to become chilled. Covering the compress with an ice pack keeps it colder longer. Re-wetting the compress helps to maintain the proper temperature.
A large ice cube is needed to perform an ice massage. Holding the ice cube by the paper cup keeps it from melting quickly and also protects the hands of the person administering the treatment. Continuously moving the ice keeps the cold temperature evenly distributed and prevents damage.
The patient should not be permitted to leave the office until the area is inspected. If damage is observed, the provider should be informed immediately.
7. Assist the patient with dressing if needed. 8. Clean the work area and wash hands.
Hands must be washed after each patient.
9. Document the treatment in the patient’s chart.
Every procedure must be documented in the patient’s chart.
DOCUMENTATION EXAMPLE:
08-16-XX 12:30 p.m.
Applied cold compress to left forearm, as per Dr. May’s orders. Pt. tolerated procedure well. Notable decrease in swelling. Pt. noted a definite decrease in pain as well. Dawn Carter, RMA
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PROCEDURE 21-3 Instruct a Patient to Use a Cane Objective: To properly adjust the height of the cane, and to instruct the patient in the proper use of the cane.
Equipment/Supplies: ❖ Cane (prescribed by provider or physical therapist)
❖ Patient’s record
PROCEDURAL STEPS
RATIONALE
1. Check the provider’s orders, assemble the equipment, and wash your hands.
Hands must be washed before each patient contact.
2. Identify the patient using two identifiers, identify yourself, and explain the procedure. 3. Inspect the tip of the cane to be sure there is a rubber tip.
The rubber tip keeps the cane from slipping on the floor.
4. Adjust the cane height so that the handle of the cane is even with the patient's hip joint and the patient’s elbow is flexed at a 25º to 30º angle. 5. Demonstrate the correct usage of the cane: a. Hold the cane on the strong side.
b. Move the cane and the affected leg forward at the same time (Figure 21-22).
c. Move the strong leg forward, slightly in front of the cane. d. Take slow, small steps.
FIGURE 21-22 Holding the cane on the strong side gives better support and balance. The patient should transfer the weight to the cane to avoid too much weight on the weak extremity.
The medical assistant demonstrates how to move the cane and the affected leg forward at the same time.
Walking slowly decreases the chance of falling.
e. Repeat b and c. 6. Apply a gait belt (an added precaution) to the patient and ask the patient to practice the procedure.
The gait belt will make it easier to hold the patient to prevent a fall in case the patient loses balance. The patient must be able to successfully walk with the cane before leaving the office.
7. Document the patient education in the patient’s chart.
All educational sessions must be documented in the patient’s chart.
DOCUMENTATION EXAMPLE:
01-11-XX 2:00 p.m.
Demonstrated proper use of cane and adjusted the height to the correct level. Pt. demonstrated proper technique using the cane. Gave patient educational handout on cane use. Ben Jancowski, CMA (AAMA)
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PROCEDURE 21-4 Instruct a Patient to Use Axillary Crutches Objective: To properly measure a patient for axillary crutches and to teach the patient how to use the five different crutch gaits.
Equipment/Supplies: ❖ Aluminum/wood axillary crutches
❖ Patient’s record
PROCEDURAL STEPS
RATIONALE
1. Check the provider’s orders, assemble the equipment, and wash your hands.
The provider’s orders must be followed as to the type of crutches and gait used.
2. Identify the patient using two identifiers, identify yourself, and explain the procedure.
Make sure that you are instructing the correct patient.
3. Inspect rubber tips at the bottom of each crutch and tighten wing nuts. Check pads on the hand grips and the axillary bars.
Inspecting these items and making any necessary adjustments will help to ensure patient safety and comfort.
4. Instruct the patient (Figure 21-23) to stand erect and place the crutches into the axillary space. The tip of each crutch should be held about 4 to 6 inches to the side of each foot.
This position will ensure correct measurement.
5. Adjust the crutches (Figure 21-24) so there is a two-fingerwidth space between the axillary bar and the armpits. The elbows should be flexed at a 25º to 30º angle.
Correct height ensures more stability and prevents injury to the nerves of the arms and hands.
6. Demonstrate the proper gait (Figure 21-25) and inform the patient not to move the crutches more than 6 inches in front of the body.
Demonstrating the procedure first will help the patient understand the instructions.
7. Allow the patient to practice. Be sure the patient is supporting her weight on the hand grips and not the axillary bar (Figure 21-26).
Supporting the weight on the axilla can cause nerve damage.
FIGURE 21-23
FIGURE 21-24
FIGURE 21-25
FIGURE 21-26
The medical assistant gives the patient instructions about how to use the crutches before getting started.
The medical assistant measures the patient with the crutches to make certain that the crutches are approximately two fingerwidths below the patient’s armpits.
The medical assistant demonstrates how to use the crutches.
The patient supports the weight on the hands, not the axilla, to avoid damaging the nerves of the arm.
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PROCEDURAL STEPS
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8. Instruct the patient to inspect the crutches regularly for damage to the rubber tips and pads and to check the tightness of the wing nuts.
Damaged parts or loose crutches could cause the patient to fall.
9. Document the patient education in the patient’s chart.
All patient education sessions must be documented in the patient’s chart.
DOCUMENTATION EXAMPLE:
05-16-XX 10:00 a.m.
Pt. was correctly fitted with axillary crutches. Demonstrated how to use the crutches for the patient per Dr. Ansel’s orders. Pt. was able to successfully demonstrate back how to use the crutches. Isabella Crawford, CMA (AAMA)
PROCEDURE 21-5 Instruct a Patient to Use a Walker Objective: To properly adjust a walker to the correct height and instruct the patient in its use.
Equipment/Supplies: ❖ Walker
❖ Patient’s record
PROCEDURAL STEPS
RATIONALE
1. Assemble the equipment and wash your hands.
Hands must be washed before each patient contact.
2. Identify the patient using two identifiers, identify yourself, and explain the procedure.
Explaining the procedure will assist the patient in knowing what to expect during the education.
3. Inspect the walker to be sure the rubber tips and hand grips are in place.
Rubber tips keep the walker from slipping on the floor.
4. Adjust the height of walker (Figure 21-27), so that the hand grips of the walker are at the patient’s hip level.
The walker must be at the correct height to ensure maximum stability.
FIGURE 21-27 The medical assistant adjusts the walker to the proper height for the patient.
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5. After demonstrating the proper procedure, instruct the patient to stand inside the walker and grip the handles. (When gripping the handles, the patient’s elbows should be flexed at a 25º to 30º angle.) Ask the patient to pick the walker up (not slide it), move it forward about 6 inches, and walk into it (Figure 21-28).
Many patients learn easier by seeing a skill demonstrated first.
6. Inform the patient that all four walker legs should be on the ground before moving forward.
All four walker legs must be on the ground before moving to keep the walker from tipping.
7. Have the patient demonstrate the procedure.
The patient must be able to use the walker correctly before leaving the office.
8. Document the patient education in the patient’s chart.
All educational sessions must be documented in the patient’s chart.
FIGURE 21-28 The medical assistant instructs the patient to move the walker forward first and then walk into it.
DOCUMENTATION EXAMPLE:
11-08-XX 10:00 a.m.
Adjusted walker to correct height and demonstrated proper procedure for using the walker, per Dr. Raymond’s orders. Pt. demonstrated correct usage. Erin Speck, CMA (AAMA)
PROCEDURE 21-6 Assist a Patient from the Wheelchair to the Exam Table and Back to the Wheelchair Objective: To correctly assist a patient from a wheelchair to the exam table and from the exam table back to the chair.
Equipment/Supplies: ❖ Wheelchair ❖ Stool
❖ Exam table
PROCEDURAL STEPS
RATIONALE
1. Wash your hands.
Hands must be washed before each patient contact.
2. Identify the patient using two identifiers, identify yourself, and apply the gait belt around the patient’s waist (Figure 21-29). Explain that you will assist them onto the exam table.
An explanation can help to alleviate the patient’s fear of falling.
3. Place the wheelchair close to the exam table and lock the wheels (Figure 21-30). Pull out the extension or place a step stool close to the exam table (if necessary).
Locking the wheels keeps the chair from moving.
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RATIONALE
PROCEDURAL STEPS 4. Release the footrests and move them out of the way.
Footrests that are not placed out of the way can catch on the patient’s clothing and may cause a fall.
5. Instruct the patient to slide forward to the edge of the wheelchair and place both feet on the floor.
Being close to the edge will allow the patient to have the best momentum when attempting to stand.
6. Stand in front of the patient and place your feet apart with one foot slightly out front.
This position gives you the best balance for lifting the patient.
7. Bend your knees (Figure 21-31) and instruct the patient to place his hands on the arms of the wheelchair. Place your hands around the patient’s waist, grasping the gait belt. Signal the patient to stand, pushing himself upward as you lift upward on the gait belt. Pause for a few seconds after the patient is standing before proceeding.
Bending your knees allows you to lift with your legs and not your back. Pausing allows the patient to gain balance.
8. Assist the patient up onto the footrest one foot at a time. Pivot the patient so that the back side of the body is against the exam table. Help the patient get into a sitting position (Figure 21-32). Move the wheelchair out of the way.
Helping the patient get into a sitting position assures that the patient is stable before you let go. Moving the chair out of the way eliminates a hazard for falling.
9. After the exam reapply the gait belt and move the wheelchair close to the exam table. Lock the wheels.
Always lock the wheels when moving a patient into or out of a wheelchair.
10. Pull out the extension. Grasp your hands underneath the gait belt and ask the patient to grasp you around your shoulders. Help the patient to step down onto the foot extension and then onto the floor one foot at a time. If the patient is very tall, the patient may step directly onto the floor.
Do not let go of the patient. The patient may be unstable after sitting on the exam table for a period of time.
11. Instruct the patient to reach behind for the arms of the chair and slowly lower the patient into the chair.
Lowering patient slowly helps to eliminate the chance of falling or injury.
12. Reposition the footrests and unlock the wheels.
It is easier to move a patient in a wheelchair if the feet are on the footrests.
FIGURE 21-29
FIGURE 21-30
FIGURE 21-31
FIGURE 21-32
The medical assistant places a gait belt around the patient’s waist.
The medical assistant locks the wheels of the wheelchair and puts the foot rests up and out of the way.
The medical assistant bends her knees to avoid injury to her back.
The medical assistant helps the patient onto the table and makes certain that the patient is stable.
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Chapter Summary With the incredible advances in medical science, an orthopedist not only treats diseases and injuries of the bones and muscles, but can now replace a worn-out joint with a new and painless synthetic one and repair badly broken bones with rods, plates, etc. Many orthopedists now employ medical assistants in their practices who can assist with exams, the measurement and use of immobilization devices, and even cast removal. The medical assistant is often the person responsible for instructing a patient in the use of assistive ambulatory devices as well. Another part of rehabilitation from an injury or surgery includes physical therapy. Physical agents, such as heat, cold, water, electricity, and sound waves, are used to help patients with pain relief as well as regaining functionality. Therapeutic exercises, such as range of motion, may also be employed to help patients maintain flexibility and strength or regain the use of injured muscles.
FIELD APPLICATION CHALLENGE An otherwise healthy middle-aged man is seen in the office with extreme mid-back pain. The patient tells the provider that he has been splitting and stacking firewood for the winter and thinks he may have hurt his back. An x-ray is taken, but there is no visible injury. The provider orders an ultrasound treatment in the area causing the pain and instructs you about the correct intensity setting and length of time for the treatment. During the treatment, the patient complains of a tingling, burning feeling in the area, but you are confident that the ultrasound
is on the correct setting, and therefore you continue the treatment for the prescribed amount of time. 1. What should you have done when the patient indicated that he was feeling something during the treatment? 2. What could be the cause of the uncomfortable sensation the patient is experiencing? 3. What can happen if a treatment is continued when the patient feels pain?
Chapter Assessment 1. Range of motion exercises would be classified as: a. physical therapy. b. occupational therapy. c. psychotherapy. d. stress therapy. 2. An example of moist heat therapy would be: a. hot compress. b. hot soak. c. heating pad. d. both a and b. 3. Which of the following physical agents would be included in cryotherapy? a. Ultrasound b. Heat packs c. Cold packs d. Electricity
4. Which of the following devices gives the patient the most stability when ambulating? a. Tripod cane b. Walker c. Crutches d. Quad cane 5. A __________ results when bones are displaced in a joint. a. strain b. sprain c. dislocation d. hairline fracture 6. All of the following are considered to be immobilization devices, except: a. walker. b. splint. c. cast. d. equalizer walking boot.
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7. Which of the following treatments or procedures would be administered or taught by the occupational therapist? a. Brushing the hair b. ROM c. Swimming d. Walking 8. A fracture in which the bone is bent but not broken all the way through is a/an: a. Colles fracture. b. spiral fracture. c. greenstick fracture. d. impacted fracture. 9. A whirlpool is considered to be which type of therapy? a. Thermotherapy b. Cryotherapy c. Myotherapy d. Hydrotherapy 10. Walking on a treadmill would be an example of what type of exercise? a. Active b. Passive c. Aided mobility d. Active resistance
Web Activities 1. Visit the National Institute of Arthritis, Musculoskeletal, and Skin Diseases Web site at http://www .niams.nih.gov/ and gather information on the Surgeon General’s report on bone health. 2. Search WebMD for the latest information on total joint replacements of the knees and hips. 3. Visit http://www.aaos.com, the Web site for the American Association of Orthopedic Surgeons, to obtain information on orthopedic conditions and treatment, injury prevention, and wellness and exercise.
CONNECTION Using your StudyWARE CD-ROM: ❖ Complete the Concentration and Crossword Puzzle activities for this chapter. ❖ Complete the Quiz for this chapter in Test Mode.
THE DVD LINK On your StudyWARE CD-ROM, go to the DVD Challenge for this chapter. View the DVD clip and respond to the following questions: 1. What did Carla do to Jerry’s back before gathering her supplies? What was the purpose of this action? 2. What should be placed between the patient’s skin and a heat or cold pack? 3. What does heat do to blood vessels? What does cold do to blood vessels? What should be applied to an acute injury site? 4. What provides the best therapy, moist or dry forms of heat or cold?
C H A P T E R
Medical and Surgical Asepsis Chapter Outline Asepsis Care and Maintenance of Surgical Instruments Soaking Instruments Sanitizing Instruments Lubricating Instruments Inspecting Instruments Disinfecting Instruments
Sterilization Techniques Dry Heat Sterilization Gas Sterilization Chemical Sterilants Autoclaving
Developmental Objectives After completing this chapter, you should be able to: 1. Correctly spell and define the essential terms. 2. Compare and contrast the differences between medical and surgical asepsis, and list actions that should be taken to prevent the spread of microorganisms from one person to another. 3. List the steps that must be taken to properly clean, disinfect, and sterilize instruments. 4. Explain possible causative factors related to discoloration of instruments and maneuverability difficulties.
22 Essential Terms asepsis aseptic technique autoclave biological indicator chemical indicator strip disinfection distilled water endospore ethylene oxide high-level disinfectant inanimate object intermediate-level disinfectant low-level disinfectant medical asepsis opened-container life reuse life sanitization shelf life sterilant surgical asepsis ultrasonic cleaner wet load
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KEY COMPETENCIES
CAAHEP
ABHES
Sanitization and Lubrication of Instruments
III.C.3.b.1.e
VI.A.1.a.4.c
Chemical Disinfection of Instruments
III.C.3.b.1.c
VI.A.1.a.4.c
Wrapping Items for Sterilization and Operation of an Automated Autoclave
III.C.3.b.1.b III.C.3.b.1.c
VI.A.1.a.4.o VI.A.1.a.4.p
5. Describe the different types of disinfecting solutions and explain under which conditions you would use each type. 6. List three different types of wrapping materials and describe the procedure that is used for wrapping instruments with sterilization paper or cloth. 7. List and describe the different methods used to sterilize items and differentiate why some methods are better than others. 8. List the chain of events that must occur in order to achieve complete sterilization. 9. List the different types of indicators that are used to confirm that parameters were met to achieve complete sterilization.
Introduction Performing tasks that incorporate medical and surgical asepsis is rather common in most ambulatory care clinics. Even in practices that do not regularly perform routine surgical procedures, personnel in the practice should have a clear understanding of their roles in preventing cross-contamination from one patient to another and to themselves. Whether it is cleaning and sterilizing a vaginal speculum or disposing of supplies from a rapid strep test, knowledge of asepsis is vitally important. When using surgical instruments, providers must be able to trust that the persons preparing the instruments did so following all the rules of asepsis. One break in the sterilization chain, whether it is during the sanitization phase or during the sterilizing process, can make the patient more vulnerable to postop infections and the practice more vulnerable to unnecessary law suits. This chapter will discuss how to properly clean and disinfect items used in a medical setting and provide knowledge on how to keep instruments in premium condition.
ASEPSIS The term asepsis means free of germs. Aseptic technique is the effort that is employed to reduce the spread of microorganisms. In order to understand how to properly care for surgical instruments, the medical assistant must fully understand the principles of asepsis. There are two types of asepsis: medical asepsis and surgical asepsis. Medical asepsis includes procedures that are used to greatly decrease the number of microorganisms and prevent them from being passed from one person to another. In a surgical environment, this would include the gathering and cleaning of all instru-
MEDICAL AND SURGICAL ASEPSIS
ments and the disinfection of all counter surfaces, trays, and flooring following the surgical procedure. Surgical asepsis includes procedures and practices used to destroy and eliminate all microorganisms from instruments and other objects before they have a chance to enter an individual. It also includes the efforts that are instituted to prevent the transfer of microorganisms to the patient during surgical procedures. Examples of practices or procedures used when performing surgical asepsis include the careful sterilization of surgical instruments, the donning of surgical attire, and the placement of surgical drapes around the surgery site. Figure 22-1 illustrates some of the differences between medical and surgical asepsis.
CARE AND MAINTENANCE OF SURGICAL INSTRUMENTS To obtain the longest life possible for a surgical instrument, great care must be instituted while preparing and processing instruments for sterilization. Chemicals, heat, and steam can be quite harsh on instruments, so medical assistants must learn techniques that will pro-
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mote sterilization while maintaining the integrity and quality of the instrument.
Soaking Instruments Some manufacturers suggest submersing soiled instruments in distilled water immediately following the surgical procedure. The immediate soaking of instruments helps to keep debris from drying on them. Minerals in tap water, especially hard tap water, may deposit crystals onto instruments, causing them to become discolored and aesthetically unappealing. Pits and crevices may also form on the instruments, making it easier for microorganisms to hide. All of these factors together may inhibit the sterilization process, thus compromising the patient’s safety. Soaking containers should be made of plastic; alternatively, metal pans may be used as long as a towel is placed in the bottom of the container. The towel will keep the instrument tips and other delicate structures from knocking against the metal surfaces of the container. Heavy or sharp instruments should be separated from delicate instruments to avoid damage caused by the heavier instruments knocking up against the more delicate instruments.
Sanitizing Instruments FIGURE 22-1 Notice the difference in procedures that are considered medical aseptic procedures and procedures that are considered part of surgical asepsis. Examples of Medical Asepsis
Examples of Surgical Asepsis
All used and unused instruments within a used surgical pack should be sanitized following the procedure. The term sanitization means to make sanitary or clean, usually by scrubbing the items with a special soap. Even though certain instruments may not have been used, nonvisible body fluids or airborne pathogens may have adhered to the instrument. Surgical soaps used to sanitize instruments should have a pH relatively close to 7, because acidic or alkaline solutions may cause deposits to form, resulting in damage to the instrument. Medical assistants should wear utility gloves to decrease their risk of becoming infected during the sanitization process (Figure 22-2). All parts of each instrument should be cleansed with a nylon bristle brush or soft toothbrush and cleaned while in an open position to assure thorough cleansing. Once instruments have been properly scrubbed, they should be rinsed once again using deionized or distilled water. Distilled water is chemically pure, which helps prevent instruments from rusting. The instruments should be thoroughly dried following the last rinse with a nonlint producing material such as muslin cloth.
Ultrasonic Cleaners An ultrasonic cleaner is a device that cleans instruments by transmitting sound waves through a cleaning
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FIGURE 22-3 The Branson Ultrasonic Cleaner, Model 1510 (Courtesy of Branson Ultrasonics Corporation.)
instrument should not be rinsed following the milk bath because rinsing could also remove the lubricant. Advantages of lubricating instruments include:
FIGURE 22-2 Utility gloves provide extra protection for the
❖ Dissolving organic debris on the box locks, which helps to prevent them from locking in one position ❖ Inhibiting the instrument from becoming discolored or rusted ❖ Providing a protective coating for the instruments.
medical assistant.
Inspecting Instruments fluid. This creates a bubbling effect, loosening debris from the instrument. In general, instruments should be in an open position and all visible debris and blood should be removed before placing them into an ultrasonic cleaner. Place only like metals together to avoid corrosion. Use surgical soaps with a pH close to 7 and adjust the water temperature to meet the manufacturer’s recommendations. Avoid placing specially plated instruments into the ultrasonic cleaner. The vibrations from the unit may knock instruments into each other, causing damage to the finish. Using ultrasonic cleaners eliminates the need for manual cleansing of instruments. Figure 22-3 shows an ultrasonic cleaner from Branson.
Lubricating Instruments Many manufacturers suggest placing instruments into a lubricating solution following the cleansing process. This is known as “milking” the instruments. Instruments are placed into the lubricating solution for 30 to 60 seconds following the cleansing process and dried according to the manufacturer’s instructions. The
Inspect all instruments for discoloration, defects, and maneuverability prior to sterilizing. Test the sharpness of scissors by cutting into tissue or latex. When cleaning clamps and hemostats, check their serrations, jaw alignment, and box locks for any defects and ascertain
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FI E L D S M A R T S Spray lubricants are becoming more common than liquid lubricants because of their simplicity and cost. Instead of submerging the entire instrument into the liquid, you can just spray the designated area. You don’t have to worry about possible contamination from previous instruments, and many sprays are less expensive to use than liquid lubricants. Some surgical soaps now include a lubricant in the cleanser, so there is no need to perform the extra step.
MEDICAL AND SURGICAL ASEPSIS
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CR ITI C A L TH I N K I N G C H AL LEN G E The physician becomes agitated because many surgical instruments are becoming discolored and the instruments with box locks are becoming more difficult to maneuver. The physician states that the instruments never looked like this when the previous medical assistant was employed with the practice. 1. What are some possible causes for the discoloration of the instruments? 2. What are some possible causes for the maneuverability concerns? 3. Using the Internet to assist you, discuss steps you can take to remove the deposits on the instruments that are causing the discoloration and to assist with the maneuverability issues.
that the ratchets are secure when closed at each interval. If any defects are found, the affected instruments should be removed from the current supply of instruments and either sent out for repair or discarded. Refer to Procedure 22-1 for instructions on sanitizing and lubricating instruments.
Disinfecting Instruments The process of using special liquids or pasteurization techniques to destroy or inhibit the growth of most microorganisms is referred to as disinfection. Disinfecting solutions are typically used to clean inanimate objects, or structures that are nonliving, such as countertop surfaces, flooring, and examination tables. Disinfectants may also be used to further clean instruments or items that cannot be autoclaved. The level of disinfectant selected is based on the type of instrument and its function. Refer to the following list: ❖ Critical items are instruments or devices that will penetrate or enter sterile tissue. These items require complete sterilization and are usually cleaned by autoclaving or through gas sterilization. Items that are either heat sensitive or will not fit into an autoclave or gas oven may be sterilized through cold sterilization using an FDA-approved sterilant. ❖ Semicritical items are instruments or devices that may come into contact with nonintact skin or
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mucous membranes, but do not penetrate them. Endoscopes are common pieces of equipment that fall under the category of semicritical devices. Many semicritical devices require the use of a high-level disinfectant, but a few semicritical items may be disinfected with an intermediate-level disinfectant (refer to Table 22-1 for clarity). ❖ Noncritical items are instruments or devices that only touch intact skin; they do not come into contact with mucous membranes or nonintact skin. Noncritical items may be disinfected with a low-level disinfecting solution.
Levels of Disinfecting Solutions There are three major levels of disinfecting solutions. The level or strength of a disinfecting solution is based on both the solution’s ability to kill particular types of microorganisms and the numbers of microorganisms that the solution can destroy. Some types of microorganisms are more resistant to particular disinfectants and may require stronger dilutions and longer submersion times. The following is a summary that lists microorganisms in order from most resistant to least resistant: ❖ ❖ ❖ ❖ ❖ ❖
Bacterial spores Mycobacteria Nonlipid or small viruses Fungi Vegetative bacteria Lipid or medium-sized viruses
Levels of disinfectants that destroy various forms of microorganisms include the following: ❖ Low-level disinfectant: Should only be used on noncritical devices. Kills most types of bacteria and some viruses. Does not kill mycobacteria or bacterial spores. Follow the dilution ratios posted on the solution’s bottle for using the solution as a low-level disinfectant. ❖ Intermediate-level disinfectant: May be used on noncritical devices and some semicritical items. Inactivates vegetative bacteria, mycobacterium, and most fungi, but does not necessarily kill spores. Follow the dilution ratios posted on the solution’s bottle for using the solution as an intermediate-level disinfectant. ❖ High-level disinfectant: May be used on items on the semicritical list. Can kill all forms of microorganisms except high levels of bacterial spores. Follow the dilution ratios posted on the solution’s bottle for using the solution as a high-level disinfectant.
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❖ Sterilant: Should be used on critical items. Refers to a high-level chemical disinfectant that has been cleared by the FDA as being capable of destroying all microorganisms, including large amounts of bacterial spores. Submersion times are usually much longer than required for use as a high-level disinfectant. Follow the exact instruc-
tions on the bottle for using as a sterilant. Sterilizing instruments through the use of sterilants is referred to as “cold sterilization.” Table 22-1 classifies devices commonly found in the medical office and the level of disinfectant used for each device. Notice that some disinfectants fit into
TABLE 22-1 Device Classification and Disinfection Level LEVEL OF DISINFECTANT NEEDED FOR EACH DEVICE CLASSIFICATION
EXAMPLES OF DISINFECTING SOLUTIONS AND SUBMERSION TIMES
Noncritical Devices: Only touches intact skin. Does not come into contact with mucus membranes. Examples include stethoscopes, blood pressure cuffs, bed rails, doorknobs, exam tables, IV poles, wheelchairs, and basins.
Low-level disinfectant Effective against: Viruses—some Mycobacteria—no Fungi—some Endospores—no
Isopropyl alcohol 70% (5 minute exposure time) Liquid sodium hypochlorite Household bleach 10% solution (5 minute exposure time) Iodophor germicidal: Wescodyne (follow the label instructions)
Semicritical Devices: Touches nonintact skin or mucous membranes. There are really two levels of semicritical devices: those that require an intermediate-level disinfectant, and those that require a high-level disinfectant. Devices that are at lower risk of spreading infection include thermometers, ear specula, and hydrotherapy tanks. These semicritical devices only require an intermediate-level disinfectant. Semicritical devices that require a high-level disinfectant are listed below.
Intermediate-level disinfectant Effective against: Viruses—varies Mycobacteria—varies Fungi—most Endospores—no
Ethyl or isopropyl alcohol 70% to 90% (exposure time less than 10 minutes) The majority of low-level disinfectants may be used as intermediate-level disinfectants at higher concentrations and with longer submersion times (refer to the label instructions).
Other Semicritical Devices: Most semicritical devices require a high-level disinfectant because of their higher risk of transmitting infection. These devices include cystoscopes, laryngoscopes, sigmoidoscopes, diaphragms used for fittings, anesthesia equipment, etc.
High-level disinfectant Effective against: Viruses—yes Mycobacteria—yes Fungi—yes Endospores—some
Glutaraldehyde-based formulas (exposure time will vary, check the label for use as a high-level disinfectant) Cidex Plus, Wavicide, Omnicide, Banicide, Metrcide, Procide Household bleach 1:50 dilution (exposure time more than 20 minutes)
Critical Devices: Enters nonintact skin, sterile tissue, or vascular tissue. Examples include scalpels, hemostats, operating scissors, etc.
Sterilant Effective against: Virsues—yes Mycobacteria—yes Fungi—yes Endospores—yes
Glutaraldehyde-based formulas listed above Exposure times may be as long as 10 hours. Follow the label instructions.
DEVICE CLASSIFICATION AND EXAMPLES
MEDICAL AND SURGICAL ASEPSIS
two or all three categories. Remember that dilution ratios and submersion times play a role in determining how the solution is classified. Read the manufacturer’s instructions to gain information for preparing the solution to obtain the proper level of disinfection.
Preparing and Storing Disinfectants Disinfectants may be caustic and cause irritation to skin and other mucous membranes; therefore, medical assistants should always wear gloves and other appropriate PPE (apron, goggles, a mask if splashing is anticipated) and work in well-ventilated areas when using disinfectants. This is particularly true when working with high-level disinfectants and sterilants. Three dates that medical assistants must familiarize themselves with when working with disinfecting solutions include: 1. Shelf life: The amount of time the solution may be stored unopened before losing its potency (the expiration date on the container). 2. Reuse life: The amount of time the solution may be used once it has been prepared or activated. 3. Opened-container life: The amount of time the disinfecting solution may be used once the bottle has been opened. Disinfecting solutions come in either “ready to use” formulas or as concentrates. Once the solution has been prepared, a label is placed on the outside of the
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FI E L D S M A R T S In general, disinfectants are applied to inanimate objects such as instruments, flooring, and countertops. Disinfectants and sterilants are also used on instruments that cannot be autoclaved, such as endoscopes. Antiseptics, which are also chemicals that reduce the number of microorganisms, are applied to living tissue or skin. There are a limited number of disinfectants that may be used as both an antiseptic and a disinfectant, the most popular of which are alcohol and iodine products.
container stating the name and strength of the solution, the date it was prepared, the date it will expire, and the initials of the person that prepared the solution. The solution should be covered with a lid to keep it from evaporating and to keep contaminants out of the solution.
Storing Chemical Disinfectants Chemical disinfectants may be hazardous in case of an accidental spill and may also be highly flammable.
Many factors can interfere with a disinfectant’s ability to destroy microorganisms, including improper dilution ratios, inadequate exposure times, failure to change the solution according to manufacturer’s instructions, or placing instruments that are wet directly into the solution. Chemical indicator strips are strips that are used when sterilizing instruments through chemical means to confirm that the necessary environmental conditions needed to achieve complete sterilization have been met. The manufacturers of sterilants have developed strips that are available to test the minimum effective concentration (MEC) of disinfecting solutions. One such solution is Serim Disintek® XL Test
Strips. You first place the strip into the solution and hold it motionless for 20 seconds. Remove the strip from the solution and place the side edge on a paper towel for 2 full seconds. Then place the strip with the indicator pad facing up on a clean paper towel for 5 minutes. The test pad will turn completely purple if the solution passes the test; if the solution fails the test, the test pad will turn blotchy or remain its original white color. The test should be performed just prior to placement of the instruments into the solution. The test strip does not tell you if you achieved disinfection or sterilization; it only tells you whether the concentration of the solution is at the desired level.
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It is essential that the medical assistant store chemical disinfectants according to the manufacturer’s instructions. All chemical disinfectants on the premises should have a material safety data sheet (MSDS) in the MSDS manual. The active ingredients in the disinfectant should be included on the MSDS form. All hazardous spills must be reported to a supervisor immediately. Refer to Procedure 22-2 for complete instructions on how to properly disinfect instruments.
STERILIZATION TECHNIQUES The term sterilization means the complete destruction of all microorganisms including endospores, which can form within particular types of bacterial cells. Endospores are very difficult to destroy because of their impermeable coating. This coating surrounds the spore, protecting it from many environmental factors including heat, ultraviolet radiation, chemicals, acids, and drying. The only methods that can eliminate endospores altogether are steam under pressure (autoclaving), certain gases such as ethyl oxide, sterilants, and prolonged exposure to radiation. Complete sterilization is essential when preparing critical care instruments and items.
Dry Heat Sterilization Dry heat is not as effective as wet heat and requires a much longer time to completely sterilize items, but it may be used to sterilize articles that may be damaged by wet heat or steam. A common temperature used for dry heat sterilization is 338°F (170°C) for 60 minutes. Dry heat is ineffective against spores.
right conditions. Proper dilution ratios and submersion lengths are factors that contribute to the solution’s ability to chemically change from the status of a disinfectant to that of a sterilant.
Autoclaving Autoclaving, or steam under pressure, is one of the most dependable forms of sterilization. The physical makeup of an autoclave can be compared to that of a pressure cooker. It combines steam under pressure (15 pounds of pressure per square inch [psi]) to reach a heat of 250°F to 254°F (121°C to 123°C). Boiling water can only reach a maximum temperature of 212°F (100°C), which is not high enough to kill spores. The autoclave sterilizes items by displacing air with steam within the autoclave’s chamber and exposing items to large amounts of heat over a specified time period. Autoclaving is not only one of the most trusted forms of sterilization, but it is also very economical. Refer to Figure 22-4 for a picture of an autoclave.
Wrapping Items to be Autoclaved Once instruments have been properly sanitized, inspected, and lubricated, they are ready for sterilization. In order to maintain sterility, items will need to be wrapped in an acceptable wrapping material; however, there are exceptions. Vaginal speculums must be sterilized between patients but do not necessarily need to be stored sterilely unless used in a minor office
Gas Sterilization
FIGURE 22-4 A standard autoclave used in today’s medical
Some larger health care facilities, such as hospitals and surgical centers, use gas to sterilize instruments. Ethylene oxide, or EtO, is one of the most common gases used for sterilization because of its ability to kill all forms of microorganisms including bacterial spores. Facilities choose gas sterilization for products that may become easily damaged by other forms of sterilization. This method of sterilization is also used in manufacturing plants that package sterile needles, sutures, and catheters. Because of the dangers of working with EtO, staff must have specialized training before operating any EtO sterilizers.
office.
Chemical Sterilants Chemical sterilants are high-level disinfecting solutions that have the capability to become a sterilant under the
MEDICAL AND SURGICAL ASEPSIS
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CR ITI C A L TH I N K I N G C H AL LEN G E State the purpose of sterilizing vaginal speculums, and describe why they don’t necessarily need to be stored in a sterile manner.
surgery. Therefore, some offices autoclave their speculums unwrapped. All critical devices and instruments should be wrapped to maintain a sterile environment following autoclaving. Instruments should always be wrapped in an open position so that the steam can penetrate each surface of the instrument. Sterilization Wraps Sterilization wraps must be permeable to steam, yet must still provide an effective barrier against the penetration of microbes and contamination from persons handling the packs prior to use. Types of wraps include:
❖ Autoclave or sterilization paper: Available in a variety of sizes and cut into squares, this paper is disposable but can be expensive. Autoclave paper is opaque, so the contents of the pack cannot be seen prior to opening. The different sizes of paper allow the person performing the wrapping the opportunity to wrap single items or large trays. ❖ Sterilization cloth wraps: Made of woven or unwoven materials, these special cloths come in different sizes and colors and are thicker than autoclave paper. They are economical because they are reusable. They open easily and are easy to handle. The cloths should be inspected prior to use for any thinning of the material, holes, or tears. If any defects are found, the cloth will need to be disposed of. ❖ Sterilization pouches: Easy to prepare and made of plastic, paper, or both, these individual pouches usually feature a peel-apart seal on one end of the pouch for easy opening. The opposite end is open so that the instrument may be inserted into the pouch. Once the instrument is placed in the pouch, the medical assistant will peel off the adhesive strip protector located above the perforation
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and fold the perforated edge over the adhesive strip, pressing firmly to seal it. Another method used to seal the open end is to seal it with a heat sealer. There are also continuous rolls of sterilization pouch material that come in a variety of different sizes and may be cut to desired lengths. Pouches made entirely or partially of plastic provide easy visibility of the contents within the pack. Each pouch includes a sterilization indicator and should be checked for a color change following the autoclaving cycle. Figure 22-5 shows a variety of different wraps, pouches, and tapes that are used when processing instruments for autoclaving. The proper method used to wrap instruments when using autoclave paper or cloth is referred to as the “fanfold” or “envelope” method of wrapping (refer to Procedure 22-3 for photos of this method). The instrument is wrapped so that it can be opened without contaminating the pack. Many facilities double wrap trays to provide extra protection from environmental factors. The medical assistant must identify three key elements on the pack or tape: 1. The name of the item 2. The date of expiration 3. The initials of the person who prepared the pack for sterilization The shelf life or length of time that packs are considered sterile following autoclaving will vary depending on the type of wrapping material used. One must also inspect the pack for any defects, such as moisture, holes, bubbles, or tears. These defects may be caused by event factors. Event factors are factors that occur as
FIGURE 22-5 A variety of wrapping supplies
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F IEL D S M A R T S
FI E L D S M A R T S
The purpose of placing the initials of the preparer on the peel-apart pack or autoclave tape is to identify who prepared the pack in case there are any problems with the pack such as missing items or debris on the instruments. You should always be proactive whenever possible by looking for problems while setting up the tray so that procedures do not have to be postponed while a new tray is opened and prepared.
Always check the following before establishing that a pack is sterile:
a result of poor wrapping, poor sealing, poor storage, and poor handling of the packs. Table 22-2 lists general shelf lives of items wrapped in different types of wrapping materials.
Proper Loading of the Autoclave
1. The expiration or sterilization date 2. The sterilization indicator to make certain it is the proper color 3. The general condition of the wrapping material to make certain that there are no signs of moisture, holes, or other defects If there are any concerns that the pack may be contaminated, follow the four “Rs”: Remove, resanitize, rewrap, and resterilize.
FIGURE 22-6 (a) The correct way to place packs in an autoclave; (b) How not to place packs in an autoclave; (c) The proper position for a jar in an autoclave; (d) The improper position for a jar in an autoclave Correct
The autoclave must be loaded properly in order for steam to circulate both through and between the packs. To avoid air pockets, packs should not be stacked on top of each other or shoved directly beside each other. Packs should be placed in a vertical position and separated by at least 1 to 3 inches. Jars should be placed on their sides with their lids ajar or removed altogether to facilitate complete sterilization of the contents within the jar. Avoid overloading the autoclave, and make certain that there is a minimum of 1 inch between each tray. Figure 22-6 illustrates the proper placement of packs and jars in the autoclave.
Incorrect
(a)
(b)
(c)
(d)
TABLE 22-2 Shelf Life of Sterile Items Wrapped with sterilization paper or cloth Wrapped after autoclaving with sterility maintenance covers Sterilization pouches
30 days
Six months Six months to a year (follow manufacturer’s instructions)
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FI E L D S M A R T S To avoid explosion, never place sealed containers in an autoclave.
MEDICAL AND SURGICAL ASEPSIS
Proper Operation of the Autoclave Each autoclave is unique, so one must always read and follow the manufacturer’s instructions; however, the general steps for autoclaving are similar from one autoclave to another: 1. Properly load the autoclave. 2. Check the water reservoir to make certain that it is at the desired level. Never use tap water in an autoclave; the minerals in the water will cause the chamber to rust. Always use distilled water. 3. Turn on the autoclave and follow the manufacturer’s instructions. In newer automated units, the medical assistant will also select the appropriate sterilization cycle. 4. Fill the chamber with water. ❖ In older nonautomated units, this is performed manually. ❖ In newer automated units, this occurs automatically. 5 Allow the temperature to climb to a minimum of 250°F (121°C) and the pressure to reach a minimum of 15 psi before the timing of the load begins. ❖ In older nonautomated units, the medical assistant must set a timer and check back to determine when the temperature and pressure have reached the desired levels. Once the unit has reached the desired level, the medical assistant may need to make an adjustment in the temperature setting so that it stops climbing and stabilizes. The timing begins once the unit has reached the proper temperature and pressure. ❖ This step occurs automatically in newer units. 6. Allow the load to run the entire length of the sterilization cycle. ❖ Refer to Table 22-3 for the length of time items should be sterilized. (Remember that the timing should not begin until the chamber has been preheated to a minimum of 250°F (121°C) and the pressure has risen to a minimum of 15 psi.) 7. Complete the ventilation cycle. ❖ In older units, the medical assistant must turn the knob to vent and allow the autoclave to completely depressurize. Once depressurized, the door should be opened slightly, between 1 ⁄2 and 1 inch. ❖ This step occurs automatically in newer units. 8. Allow the load to go through the drying cycle, if applicable.
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FI E L D S M A R T S When venting one of the older models of autoclaves, never open the door more than 1⁄2 to 1 inch. The cold air from the outside can rush into the hot chamber and cause condensation to occur, resulting in wet packs. This is commonly referred to as a wet load. Because the integrity of the wrap is now in question, the whole process must be repeated.
Sterilization Indicators There are a variety of indicators that may be used to ascertain that ideal environmental conditions have been reached within the autoclave in order for proper sterilization to occur. Sterilization indicators are available from a number of suppliers. Some of the various types of indicators include: ❖ Process indicators: Process indicators distinguish whether an item has been processed or autoclaved. These indicators change to a distinct color for confirmation purposes. Autoclave tape is an example of a process indicator. ❖ Internal indicators and integrators: Temperature, timing, and saturation of sterilant are three critical parameters that are used to determine that conditions are ideal for complete sterilization. Internal indicators will demonstrate that the ideal temperature was achieved both inside and outside the pack. A multiparameter indicator or internal
TABLE 22-3 General Length of Time Items Should Be Sterilized Unwrapped Items
20 minutes
Single wrapped items or items that are loosely wrapped
30 minutes
Double wrapped items or items that are tightly wrapped
40 minutes
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SITE CHECK FIGURE 22-7 An example of an autoclave chemical indicator strip
One of the items I will check for when surveying an office is a copy of the practice’s sterilization quality assurance program. I will also check for accurate record keeping regarding the use of chemical and biological indicators. Every time a load is sterilized, the operator should list the date and time of the load and methods used to measure sterilization parameters. This should all be recorded in an autoclave log. Some offices tape all chemical indicators to the log pages as well as keeping copies of reports received for each biological test performed. If results were unsatisfactory, I will look to see what was done to remedy the problem.
FIGURE 22-8 Offices should run weekly spore checks by placing a biological indicator in the autoclave with a regular load.
integrator will indicate that temperature, timing, and saturation of sterilant was achieved in order for proper sterilization to occur. Indicators may be in the form of a strip that changes color (Figure 22-7) or a melting pellet. ❖ Biological indicators (Figure 22-8): These indicators are used to check that all parameters including temperature, timing, sterilant, and humidity were met for the unit’s ability to kill endospores. Strips impregnated with heat-resistant endospores are placed in the center of a wrapped article and placed into a full autoclave. Once the cycle is completed, the spore strip is removed and sent to a monitoring lab where it is cultured. If the autoclave is working properly, there should be no growth. Results are usually faxed or e-mailed back
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F IEL D S M A R T S Sterilization indicators do not guarantee that complete sterilization of the pack was achieved, only that the parameters for effective sterilization were met. Ineffective sanitization of the instrument would not be detected by a sterilization indicator.
to the provider’s office where they are kept in a log for reference purposes. Spore checks should be performed at a minimum of once per week.
Maintaining the Autoclave Because the autoclave is so important in preventing infections, measures must be instituted to ensure proper maintenance. Proper maintenance includes internal and external inspection of the unit, proper cleansing of the unit, and the implementation of a quality assurance program through the use of chemical and biological indicators. Daily maintenance includes the inspection and cleaning of the autoclave’s interior and exterior with a damp cloth. The medical assistant should look for any concerns such as frayed electrical cords and problems with the rubber gasket. Weekly maintenance may include a thorough cleansing of the autoclave by running a commercially approved cleanser through the autoclave, such as Omni Cleaner. Offices should also perform weekly spore checks. If the spore test results are positive, another test should be immediately performed prior to the sterilization of any more instruments. If the second spore test comes back positive, the autoclave should not be used again until after it has been properly serviced and the problem resolved.
Interruption in the Sterilization Chain of Events In order for proper sterilization to occur, there can be no interruptions in the chain of events that must occur in order for sterilization to take place (Figure 22-9).
MEDICAL AND SURGICAL ASEPSIS
(a)
(c)
(d)
(e)
FIGURE 22-9 An example of the chain of events that must take place in order for sterilization to be achieved. One break in the chain nullifies all other steps. The item will not be sterile.
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The sterilization chain of events should not be confused with the chain of infection. a. b. c. d. e.
(b)
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The instrument must be properly sanitized. The instrument must be wrapped properly. The instrument must be loaded properly. The instrument must be sterilized properly. The instrument must be stored correctly.
The medical assistant must make certain that there are no interruptions in the chain. If there are any interruptions, the medical assistant must start the whole process over from the beginning. Refer to Procedure 22-3 for complete instructions on how to wrap instruments and run the autoclave.
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PROCEDURE 22-1 Sanitization and Lubrication of Instruments Objective: To properly cleanse instruments in order to minimize the risks of postop infection to the patient and to keep the instruments in excellent working order.
Equipment/Supplies: ❖ ❖ ❖ ❖
Sink Surgical soap or sanitizer Distilled or deionized water Basins (one for soaking and one for washing)
PROCEDURAL STEPS
❖ ❖ ❖ ❖
Scrub brush Waterproof drape Muslin cloth or equivalent Lubricating spray
RATIONALE
1. Wash your hands and apply the appropriate PPE.
Applying appropriate PPE will help to decrease the chances of passing microorganisms from the instruments to the medical assistant.
2. Soak items in a lined metal basin or plastic basin with deionized or distilled water.
Soaking the instruments will keep debris from drying on the instrument. Using distilled or deionized water will prevent chemical deposits from building up on the instruments that could result in instrument discoloration and incomplete sterilization.
3. Pour the water out of the first basin, protecting the instruments. Place the instruments into a new basin filled with warm water and an approved neutral cleanser made especially for surgical instruments.
It is important to use a neutral cleanser to help avoid buildup that can occur from using acidic or alkaline solutions.
4. Thoroughly scrub each part of the instruments. Pay close attention to parts of the instruments that contain crevices, teeth, and serrations (Figure 22-10).
Microorganisms can hide in hard-to-clean surfaces, such as crevices, teeth, and serrations. It is important to make certain that the whole instrument is properly sanitized or complete sterilization cannot occur.
5. Thoroughly rinse each instrument in distilled water or an approved rinsing solution.
Rinsing in distilled water prevents deposits from building up on the instruments.
6. Place each instrument on a waterproof drape until all instruments have been thoroughly sanitized and rinsed.
Laying the instruments on a towel that is not waterproof will allow the instrument to pick up microorganisms from the surface underneath the towel, causing the instruments to become recontaminated.
7. Dry each instrument with a muslin cloth or comparable material.
Drying instruments with paper products or towels may deposit lint onto the instrument, which could inhibit sterilization.
FIGURE 22-10 The medical assistant must scrub all parts of each instrument, but must scrub especially well where there are crevices, teeth, or serrations.
MEDICAL AND SURGICAL ASEPSIS
PROCEDURAL STEPS 8. Inspect each instrument for any defects. Remove any instruments that are damaged.
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RATIONALE Instruments that have defects could inhibit complete sterilization and could create problems during the procedure itself.
9. Soak each instrument in lubricating solution or spray instrument lubricant directly onto any instruments with box locks to keep the instruments working properly (Figure 22-11).
FIGURE 22-11 The medical assistant applies lubricating spray to the box lock of the instrument to keep it functioning correctly.
10. Dry the lubricated instruments according to the instructions found on the lubricant label.
Each lubricant is different.
11. Prepare the instruments for disinfection or wrapping.
This usually means moving the instruments to the appropriate room and assembling items necessary for wrapping or disinfection.
12. Clean the area using an approved disinfectant.
This cuts down on the number of microorganisms from the previously dirty instruments.
13. Remove PPE and wash your hands.
PROCEDURE 22-2 Chemical Disinfection of Instruments Objective: To properly cleanse and disinfect instruments that are sensitive to heat or that do not fit into an autoclave.
Equipment/Supplies: ❖ ❖ ❖ ❖ ❖
Chemical disinfectant Chemical solution indicator strip Airtight container Sterile water (for critical devices) Distilled water (for noncritical devices)
PROCEDURAL STEPS
❖ Sterile/clean drying cloths ❖ Sterile transfer forceps/sterile gloves (for critical devices) ❖ Clean gloves (for noncritical devices) RATIONALE
1. Choose a room that is well ventilated and clean.
The fumes from high-level disinfectant can be toxic to the lungs.
2. Wash your hands, gather the supplies, and apply the appropriate PPE. (Check the expiration date on the indicator strips and disinfecting solution to make certain that neither are expired.)
Applying the appropriate PPE will help to protect the medical assistant from possible splashing or inhalation of the chemical.
3. Prepare and pour the solution into an acceptable disinfecting container following the manufacturer’s instructions.
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continued
PROCEDURAL STEPS
RATIONALE
4. Record the date that the solution was opened on the disinfecting bottle and record the date that the solution was made on the disinfecting container. Place your initials on the disinfecting container.
The container that houses the solution is only good for a certain amount of time once the solution has been opened. This is referred to as the opened-container life of the solution. The dilution in the disinfecting container is only viable for a certain number of days once it has been made. This is referred to as the reuse life of the solution.
5. Place a chemical indicator strip into the solution following the manufacturer’s instructions (Figure 22-12). Remove and read the strip. If the strip does not meet the MEC guidelines, repeat the test. If it still does not meet the guidelines, make a new dilution. Repeat the test.
Chemical indicator strips test the minimum effective concentration (MEC) of disinfecting solutions to ascertain that the solution is at the appropriate concentration. If not, the instrument may not be disinfected or sterilized correctly, which places the patient at risk for infection.
6. Place the instrument to be disinfected into the disinfecting tray and lower the tray so that the entire instrument is completely submerged in the disinfecting solution (Figure 22-13). Shut the lid on the solution so that it is secure.
If the entire instrument is not submerged, the instrument will not be properly disinfected.
7. Set the timer according to the manufacturer’s instructions.
Set the timer so you don’t forget about the instrument. Reduced submersion times could inhibit the item from being properly disinfected or sterilized. Increased times could result in damage to the instrument.
8. Record the date and time that the instrument was submerged into the instrument disinfecting log with your initials.
For proper timing purposes.
9. When the timer goes off, lift the tray out of the disinfecting solution and rinse the item according to manufacturer’s instructions. (If solution is used as a sterilant, rinsing is usually performed by pouring sterile water over the item.)
Adequate rinsing is imperative to keep residue off of the instrument.
10. If the instrument is a critical device, dry the instrument in a sterile manner, usually with the use of sterile gloves and a sterile cloth. Clean cloths may be used for nonsterile items. (When transferring a critical device, use either sterile transfer forceps or wash hands and apply sterile gloves before handling the instrument. Noncritical devices should be handled with clean gloves when moving to a storage container.) 11. Critical devices should be used immediately since it will be impossible to store them in a sterile manner. Noncritical devices should be placed in an airtight container.
FIGURE 22-12 The disinfecting solution must be checked to be sure it meets the minimum effective concentration level.
FIGURE 12-13 The entire instrument must be completely submerged in the solution so that all parts are completely covered by the solution.
Because the instrument is not wrapped, it will be very difficult to store it in a sterile manner.
MEDICAL AND SURGICAL ASEPSIS
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RATIONALE
PROCEDURAL STEPS 12. Clean the area and replace items. 13. Remove PPE and wash your hands.
Start and end times assure those using the instruments that the instruments were disinfected for the proper amount of time.
14. Record the procedure in the instrument disinfection log.
DOCUMENTATION EXAMPLE: INSTRUMENT DISINFECTING LOG
DATE OF DISINFECTION
NAME OF INSTRUMENT
MEC CONTROL RESULT (AFFIX INDICATOR STRIP)
01-12-XX
Nasal Speculum
Acceptable
NAME AND STRENGTH OF SOLUTION
START TIME
END TIME
INITIALS
Cidex Plus
9:30 a.m.
10:00 a.m.
MH, CMA
PROCEDURE 22-3 Wrap Items for Sterilization and Operate an Automated Autoclave Objective: To correctly wrap items so that sterilization can be achieved and the instrument or tray can maintain sterility following autoclaving, and to properly operate the autoclave to assure proper sterilization of the items in the pack.
Equipment/Supplies: ❖ Sanitized instruments or tray ❖ Wrapping materials (sterilization paper, muslin cloth, or plastic seal pouch) ❖ Autoclave tape ❖ Sterilization indicator strip
❖ ❖ ❖ ❖
PROCEDURAL STEPS
RATIONALE
Permanent marker Autoclave Distilled water Pot holder or thermal gloves
1. Wash your hands and gather the supplies. 2. Don a set of clean gloves.
Even though the items have been sanitized, they may still contain bacteria that will not be removed until the items are sterilized.
3. Check the integrity of the wrapping materials for any flaws.
If there are signs of moisture, holes, or tears, the wrapping material should be discarded and replaced with appropriate wrapping materials.
4. Check the expiration date on the sterilization indicators.
Sterilization indicators may not be effective if they are expired.
5. Place the items on a clean, dry, flat surface.
A wet surface may compromise the integrity of the wrap. continues
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continued
PROCEDURAL STEPS
RATIONALE
Items to be Wrapped in Paper or Muslin: 6. Place one or two sheets of paper or muslin cloth facing diagonally so that they resemble a diamond.
This assists with proper wrapping.
7. Place the sanitized instrument in the center of the paper. Completely open instruments with hinges and shield any sharp tips with a piece of gauze. Place a sterilization indicator beside the instrument (Figure 22-14).
The instruments are opened up so that steam is able to penetrate each surface of the instrument. The cotton or gauze keeps sharp tips from piercing through the paper. The indicator strip will indicate if conditions were adequate for sterilization to occur within the pack.
8. Take the bottom edge of the paper that is facing you and fold it upward. Fold the top edge of the diagonal back toward you so that there is a flap (Figure 22-15).
(Fan-Folding Procedure) The flaps are the only part of the pack that can be touched while opening.
9. Fold one side corner of the wrap toward the center line. Fold the tip back so that there is a flap (Figure 22-16).
(Fan-Folding Procedure)
10. Repeat step 9 for the other side (Figure 22-17).
(Fan-Folding Procedure)
11. Fold the pack upward from the bottom edge until the article is completely covered (Figure 22-18).
(Fan-Folding Procedure)
12. If double wrapping, place the wrapped item onto the center of a second piece of autoclave paper (Figure 22-19). Repeat steps 7 through 11.
Double thickness provides extra thickness for heavier packs and protection from external environmental factors.
13. Secure the point that is left with autoclave tape. The following items should be recorded on the tape with permanent ink: the name of the instrument or pack, the date of sterilization, and your initials (Figure 22-20).
Securing the pack with tape will help prevent the pack from becoming contaminated. The stripes on the tape will indicate if the environment in the autoclave was adequate for sterilization to take place.
Items in Plastic Peel-Apart Wrap: 14. Write the name of the item on the envelope.
You can’t always determine the exact type of instrument through the plastic, particularly if the tips are covered with gauze.
15. Place handled instruments in the envelope (handle first).
This is so the handle is the first part of the instrument exposed upon opening.
16. Pull the backing off of the adhesive strip and bend the adhesive flap downward so that it completely seals the envelope. 17. Finish wrapping all other items that are to be autoclaved and arrange the items on the autoclave trays so that the steam can penetrate all surfaces of each instrument. Packs should be placed in a vertical position and separated at least 1 to 3 inches (Figure 22-21). Jars should be placed on their sides with their lids ajar or removed altogether to facilitate complete sterilization of the contents within the jar.
Packs must be placed in the autoclave to avoid air pockets and to facilitate the flow of steam throughout the chamber.
MEDICAL AND SURGICAL ASEPSIS
❖
FIGURE 22-14 Place the instrument for sterilization in the center of the pack with a sterilization indicator.
FIGURE 22-15 Fold the first flap toward the center leaving a small corner turned back on itself.
FIGURE 22-16 Fold one side flap toward the center, leaving a small corner turned back on itself.
FIGURE 22-17 Fold the
FIGURE 22-18 Fold the package up from the bottom and secure it.
FIGURE 22-19 Wrap the
FIGURE 22-20 Record the name of the instrument, the expiration date, and your initials on the autoclave tape.
FIGURE 22-21 Place the packs so that they are in a vertical position at least 1 to 3 inches apart.
first package in another wrap.
PROCEDURAL STEPS
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other side toward the center, leaving a small corner turned back on itself.
RATIONALE
18. Check the gauge of the autoclave reservoir and add distilled water to the fill-line (if applicable).
Water is used with each load and must be replaced. Distilled water will keep the reservoir from rusting.
19. Place trays in the autoclave. Make any necessary adjustments to accommodate the proper positioning of the instruments on each tray.
The packs may have slipped during transporting from the autoclave table to the autoclave.
20. Close and latch the door according to manufacturer’s instructions.
The door must be adequately sealed in order for the unit to function properly.
21. Select the appropriate sterilization cycle according to the load’s contents and press the start button. The load will run through the entire cycle and will even vent on its own.
The cycle will be determined by the load’s contents. Running the load on a setting that does not match the load’s contents will result in inadequate sterilization.
22. Once the load has properly vented, open the door according to the manufacturer’s instructions.
Automated units will vent the door automatically.
23. If time permits, allow items to remain in the autoclave for an additional 20 to 30 minutes to facilitate drying.
This allows more drying time for the instruments that are inside. If the packs are wet, the integrity of the wrap will be compromised and the entire pack will need to be rewrapped and resterilized.
24. Pull out the trays using caution. You may need to wear thermal gloves or use a towel to pull out the trays. (If the trays are allowed to cool before removing, just wear clean gloves to keep the outside of the packs as clean as possible.)
The trays may be hot.
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RATIONALE
PROCEDURAL STEPS 25. Remove the items and check to make certain that the stripes on the autoclave tape turned the appropriate color.
If the stripes are not the appropriate shade, sterilization may not have occurred. The load will have to be reprocessed.
26. Store the items in a clean, covered environment.
This is necessary to maintain sterility of the packs.
DOCUMENTATION EXAMPLE: INSTRUMENT AUTOCLAVE LOG
DATE
START TIME
FINISH TIME
01-12-XX
1:30 p.m.
2:15 p.m.
ITEMS AUTOCLAVED
2 Laceration Trays 2 Wrapped Vaginal Speculums
CONTROLS USED TO TEST STERILITY
Autoclave Tape Chemical Indicator Pellet
RESULTS OF CONTROLS
Both Tape and Indicator Pellet Positive for Sterilization
INITIALS
DE, CMA
Chapter Summary Health care workers must have a strong knowledge of medical and surgical asepsis in order to prevent the transfer of pathogenic microorganisms. Instituting medical asepsis sets the stage for surgical asepsis. An instrument can’t be sterilized without first removing tissue, blood, and other body fluids left on the instrument from a previous surgery. There can be no interruptions during instrument processing that compromise the sterility of instruments used to perform sterile procedures. Check points must be instituted along the way to help ensure that sterility was not only attained but also maintained from processing to the actual surgery itself. Instrument processing can be very harsh on instruments. Providers want to know that workers will take all necessary steps to obtain the greatest life span out of each instrument. Medical assistants who have a strong knowledge of aseptic procedures will be very valuable, particularly in offices that perform surgical procedures.
FIELD APPLICATION CHALLENGE You are setting up a sterile tray for a minor surgical procedure. It has been a hectic day and you are now running behind schedule. The provider is getting antsy. You retrieve the tray of instruments from storage and notice a small tear in one of the packages. This is the last package with the type of instruments required for the procedure, so you open the pack and place the contents on the sterile field.
1. What should you have done when you noticed the tear in the pack? 2. What are the possible ramifications of your actions?
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Chapter Assessment
Web Activities
1. Which type of asepsis decreases the number of microorganisms and prevents the spread of disease from one person to another? a. Surgical b. Medical c. Personal d. Public
1. Type the following words into a search engine: disinfectants used as sterilants. List three disinfectants that can be used as a sterilant, and list the length of time articles must be immersed when using the solution as a sterilant.
2. Which of the following steps would come first in the cleaning and sterilization of instruments? a. Soaking b. Sanitizing c. Disinfecting d. Wiping dry 3. Another term for the lubrication of an instrument is: a. coaxing. b. milking. c. oiling. d. none of the above. 4. Into which category would a scalpel fall with regards to disinfection? a. Semicritical b. Noncritical c. Critical d. Extremely critical 5. What is the lowest form of disinfectants that can be used on noncritical items? a. High-level b. Intermediate-level c. Low-level d. Low-level sterilant 6. What item is placed in each autoclave load to ensure that sterilization was achieved? a. Autoclave tape b. Chemical indicator strip c. Spores d. None of the above 7. Items that could be damaged in the autoclave are usually sterilized by which method? a. Dry heat b. Cold c. Gas d. Chemical
2. Type the following words into a search engine: Infection Control Today. Click on the Web site for this periodical and select a category that focuses on sterile processing and central service issues. Select an article on wrapping materials. From the article, write a one page summary about the pros and cons of using different types of wrapping material.
CONNECTION Using your StudyWARE CD-ROM: ❖ Complete the Flash Cards and Hangman activities for this chapter. ❖ Complete the Quiz for this chapter in Test Mode.
THE DVD LINK On your StudyWARE CD-ROM, go to the DVD Challenge for this chapter. View the DVD clip and respond to the following questions: 1. What was the method that the medical assistant used to wrap the instrument? 2. What did the medical assistant place in the pack to ensure that all conditions were met to achieve sterilization? 3. Why did the medical assistant insert cotton balls between each pack before placing in the autoclave? What do you know about the permeability of cotton balls? (This procedure may not be acceptable to your instructor or employer; check institutional guidelines before using.) 4. What temperature and pressure did the autoclave have to climb to before the timer kicked in?
C H A P T E R
Instrument Identification and Tray Setups Chapter Outline Types of Instruments Used in Minor Surgery Identifying the Parts of a Surgical Instrument Categories of Instruments Solutions and Supplies Used for Minor Surgery Common Solutions Used in Minor Surgery Common Supplies Used in Minor Surgery Common Anesthetics Used in Minor Surgery
Suture Materials Other Supplies Used to Close the Skin Types of Procedures Performed in the Medical Office/Tray Setups Procedures That Require No Special Equipment Procedures That Require the Use of Special Equipment, Lasers, or Chemicals
23 Essential Terms abscess anesthetic aspiration atraumatic needle box lock cryosurgery dissect electrocoagulation electrodesiccation electrofulguration electrosection electrosurgical procedure fenestrated handle jaws laceration laser ligature ratchet sebaceous cyst serrations continues
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KEY COMPETENCIES
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CAAHEP
ABHES
Application of Sterile Skin Closures
III.C.3.b.4.f
VI.A.1.a.4.h
Suture and Staple Removal
III.C.3.b.4.f
VI.A.1.a.4.h
shank surgical adhesive surgical wick suture traumatic needle
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Developmental Objectives After completing this chapter, you should be able to: 1. Correctly spell and define the essential terms. 2. List the parts of various instruments and explain their functions. 3. Identify common instruments used in ambulatory surgery and explain their uses. 4. List instruments, supplies, and special equipment necessary for common tray setups in the medical office. 5. List five common solutions used in minor surgery and explain their use. 6. Describe the function of a surgical wick. 7. List and describe four types of anesthesia. 8. Compare and contrast the differences between a suture and a ligature. 9. List and explain various ways to close the skin other than sutures and staples. 10. List five different types of surgical procedures. 11. List different types of equipment and chemicals used in minor office surgeries. 12. Explain how a laser works.
Introduction Providers use a variety of instruments and trays to perform minor surgical procedures. Medical assistants must be able to correctly identify instruments so that they can retrieve instruments in an expedient manner, correctly sanitize and process instruments, and assimilate surgical trays. Knowing how various instruments work will assist the medical assistant with instrument processing and general maintenance. Instruments are not the only items necessary to perform sterile procedures. The provider will also need many other items, including suture material, gauze sponges, antiseptic solutions, irrigating solutions, anesthetics, and a host of other supplies. This chapter will introduce the many items used during surgical procedures and will explain the medical assistant’s role in preparing for those procedures.
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TYPES OF INSTRUMENTS USED IN MINOR SURGERY Before medical assistants can become proficient in assisting providers with minor office surgeries, they must first become proficient at identifying instruments that are routinely used during those procedures. There are literally thousands of instruments used in the health care setting; however, only a small number of those instruments are used to perform minor office surgeries. Surgical instruments are generally made of stainless steel and have a shiny or dull finish, but some instruments are made of plastic and are completely disposable.
Identifying the Parts of a Surgical Instrument Knowing the different parts of an instrument will assist the medical assistant in determining the instrument’s identity and will be useful when performing cleansing and maintenance functions. ❖ Handles: The handle is the part of the instrument that the surgeon uses to hold the instrument. The majority of minor surgical instruments have either a thumb handle or a ring handle. A thumb handle (Figure 23-1) is held between the index finger and thumb and is opened and closed by pinching and releasing. Instruments with these types of handles, including different types of forceps, are generally used to grasp or pick up items. A ring handle (Figure 23-2a) has two rings: one ring is for the thumb and the other ring is for the index finger. Ring-handled instruments contain ratchets, which allow the tips of the instrument to close at varying intervals. Examples of ring-handled instruments include hemostats, needle holders, and Kelly forceps. ❖ Ratchets: The ratchet (Figure 23-2b) of a surgical instrument is centered between the two rings of a ring-handled instrument and is the locking mechanism that tightens or locks the tips of an instrument at varying degrees. ❖ Shanks: The shank (Figure 23-2c) of an instrument connects the handle with the working end of the instrument. The singular term shank is used when the instrument has only one shank, such as the shank of a scalpel. The plural shanks is used when the instrument is double-sided, such as the shanks of a pair of hemostats or forceps. Shanks are really extensions of the instrument and will
Thumb handle
FIGURE 23-1 Potts-Smith dressing forceps (Courtesy of Miltex, Inc.)
(e) Jaws
(f) Serrations
(d) Box lock
(a) Ring handles (c) Shanks
(b) Ratchet
FIGURE 23-2 Kelly forceps (Courtesy of Miltex, Inc.)
vary in length. Instruments with shorter shanks are designed to work in more superficial tissue, while instruments with longer shanks are designed to work in deeper tissue. ❖ Box locks: The box lock (Figure 23-2d) is a special type of hinge found on a variety of ringhandled instruments.
Tips of Instruments The tip of the instrument will usually indicate its use. Tips can be quite delicate and may be damaged if not handled properly. Because the tips are the part of the instrument that will touch the patient’s tissue, they are usually the dirtiest part of the instrument. Because of this, extra care should be taken when sanitizing this portion of the instrument. The following are some examples of different tips found on various types of instruments. ❖ Jaws: The jaws (Figure 23-2e) are the tips of certain instruments that are used to grasp or clamp items. Some instruments have crevices etched into their tips which are referred to as serrations. Serrations (Figure 23-2f) help to improve gripping power when working with tissue that is slippery. Serrations may be found on needle holders, forceps, and hemostats. The jaws of other instruments may be plain or contain varying numbers of teeth (Figure 23-3), which are used
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to puncture tissue. Instruments with small teeth are referred to as “mouse-toothed instruments,” while instruments with large teeth are referred to as “rat-toothed instruments.” Numbers found on instruments that contain teeth identify the number of intermeshing teeth present on the instrument. A tissue forceps is an example of an instrument with jaws that contain teeth. ❖ Circular blades: The tips of some instruments are in the shape of a loop (Figure 23-4). These loops are actually blades that are blunt on the outside and sharp on the inside. They are commonly used to remove tissue from a cavity. Examples of circular blades include uterine curettes, cervical curettes, and ear curettes. ❖ Prongs and hooks: Some instruments have pronged tips (Figure 23-5a) or hooks (Figure 23-5b) that are used to retract, lift, and explore tissue. ❖ Blades: Blades may be blunt (Figure 23-6a) or sharp (Figure 23-6b), straight or curved, and are used to cut tissue, suture material, and bandaging supplies. Bandage scissors, scalpel blades, and operating scissors (Figure 23-7) are all examples of instruments with tips that contain some sort of blade. There are many other types of tips found on other types of instruments. Just remember that the tip will most often help to identify the instrument and its use.
❖
Teeth
FIGURE 23-3 Allis tissue forceps (Courtesy of Miltex, Inc.)
Circular blade or loop
FIGURE 23-4 Sims uterine curette (Courtesy of Miltex, Inc.)
Prongs
Hook
(a)
(b)
FIGURE 23-5 Rake retractors (a) with three prongs and (b) with one prong hook end (Courtesy of Miltex, Inc.)
Categories of Instruments Instruments used in minor surgery can be grouped into four major categories: ❖ ❖ ❖ ❖
Instruments used for cutting and dissecting Instruments used for grasping and clamping Instruments to improve visualization (dilators) Instruments for probing
(a)
(b)
FIGURE 23-6 Standard scalpel handle assortment: (a) blunt; (b) sharp (Courtesy of Miltex, Inc.)
TOOL BOX
F IEL D S M A R T S To check the sharpness of scissor blades, try cutting through a rubber glove or a piece of gauze prior to sterilization. If the blades appear dull, they will probably need to be sharpened.
FIGURE 23-7 Standard operating scissors (Courtesy of Miltex, Inc.)
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Instruments Used for Cutting and Dissecting Instruments that are used for cutting and dissecting (see Table 23-1) will usually have sharp edges or tips to cut through skin, tissue, and suture material. The term dissect means to cut open or cut apart. Frequently, a surgeon will need to dissect tissue in order to explore for irregular growths or to remove abnormal tissue. Care must be taken when working with these instruments to avoid injuries. Personnel responsible for maintaining these instruments may also be responsible for inspecting the instruments and determining if they need to be sharpened at the time of instrument processing.
Instruments Used for Grasping and Clamping Instruments that are used for grasping and clamping (see Table 23-2) are primarily used for holding onto
tissue and clamping off tissue and blood vessels that may get in the way during a surgical procedure. During the sanitization process, the medical assistant must check to make certain that the locking mechanisms are working correctly on these instruments and that the instruments are lubricated for easy opening and closing.
Instruments to Improve Visualization It is difficult or even impossible to view certain body structures without the aid of special instruments or devices (see Table 23-3). These instruments are designed to assist the provider in opening structures and moving other structures out of the way in order to provide an opportunity to view organs that cannot be seen externally.
TABLE 23-1 Instruments Used for Cutting and Dissecting NAME OF INSTRUMENT Curettes Fox dermal curette (Courtesy of Miltex, Inc.)
Sims uterine curette (Courtesy of Miltex, Inc.) Buck ear curette (Courtesy of Miltex, Inc.)
DESCRIPTION/INDICATIONS Curette comes from the French name curer, which means “to clear or clean.” It is a surgical instrument that is shaped like a spoon or loop, and is used to scrape and remove tissue from the skin or body cavities. The loop is a circular blade that is sharp on the inside and blunt on the outside so that it doesn’t cause damage to the surrounding tissue. There are many different types of curettes. Below are some of the more common forms. Dermal curettes are used to shave tissue from the skin, such as lesions or melanomas. Uterine curettes are used to obtain tissue from the endocervical and uterine area for the detection of uterine cancer. Ear curettes are used to remove tissue from the ear, and are especially good for the removal of cerumen, or earwax.
Scalpels and blades Size 3 scalpel handle (Courtesy of Miltex, Inc.)
Size 9 scalpel handle (Courtesy of Miltex, Inc.)
Standard scalpel blade assortment (Courtesy of Miltex, Inc.)
A scalpel or surgical knife is used to make incisions. Typically, the blade is disposable and the handle is reusable; however, the instrument may be completely disposable. Both the handles and the blades come in a variety of sizes and must be matched to fit one another. The numbers on the blade do not match the numbers on the handle; however, only certain size blades fit onto specific handles. The most popular size handle is the number 3 handle. The number 3L (long) and number 7 handles are used when cutting deeper tissue. The size and shape of the blade is selected based on the type of tissue to be cut. The larger the blade’s number, the smaller or finer the blade. Blades range in size from 10 to 25. The most common size blades used in minor office surgeries are the numbers 10, 11, and 15. The number 11 blade is often referred to as a stab blade because of its unique point. Blade shapes include the following: straight (tip is pointed), commonly used for incision and drainage, concave (tip points inward), commonly used to cut fine or delicate tissue, and convex (tip points outward), commonly used to extract tissue.
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TABLE 23-1 Instruments Used for Cutting and Dissecting (continued) NAME OF INSTRUMENT
DESCRIPTION/INDICATIONS
Scissors
Lister bandage scissors (Courtesy of Miltex, Inc.)
The word scissors always ends in “s” because each pair of scissors has two blades. Scissors are usually sharp so that they can cut tissue, but come with a variety of options. The blades may be straight or curved and the tips can be sharp or blunt. You may also mix the tips. Tips are described in the following fashion: s/s (sharp/sharp), b/b (blunt/blunt), and s/b (sharp/blunt). Bandage scissors are used for cutting tape, gauze, bandages, and dressings. The blade tip that slips under the dressing is blunt to prevent accidental injury of the patient’s skin while removing bandages. Suture or stitch scissors are used to remove sutures. They have a blunt front with a hook to hold the suture.
Spencer stitch scissors (Courtesy of Miltex, Inc.)
Operating scissors are used to cut through tissue. They may have a sharp or blunt tip.
Standard operating scissors, blunt and straight (Courtesy of Miltex, Inc.)
Operating scissors, sharp and straight (Courtesy of Miltex, Inc.)
TABLE 23-2 Instruments Used for Grasping and Clamping NAME OF INSTRUMENT
DESCRIPTION/INDICATIONS
Forceps Dressing or thumb forceps, plain (Courtesy of Miltex, Inc.)
Adson tissue forceps (Courtesy of Miltex, Inc.)
Forceps are used to grasp and hold tissue and other items. The term forceps is used for both the singular and plural form of the word. Ring-handled forceps have ratchets to hold the instrument closed at varying tensions. Thumb-handled forceps must be manually squeezed in order to close. Thumb or dressing forceps have thumb handles and look like a set of tweezers. They may come with or without serrated jaws. They are used to grab tissue and to pack wounds. Tissue forceps generally have teeth and are used to grasp tissue. They come with either thumb handles or ring handles.
Allis tissue forceps (Courtesy of Miltex, Inc.)
continues
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TABLE 23-2 Instruments Used for Grasping and Clamping (continued) NAME OF INSTRUMENT
DESCRIPTION/INDICATIONS
Forceps (continued) Splinter forceps (Courtesy of Miltex, Inc.)
Splinter forceps have a very sharp point and come with a variety of handles. They are commonly used to remove splinters or small objects from tissue. Sponge forceps may have large rings or long tips, and may be curved or straight. They are used to apply and remove sponges for absorption and cleaning purposes
Foerster sponge forceps (Courtesy of Miltex, Inc.)
Hemostats
Hemostats are a type of forceps, although they are often referred to solely as a hemostat. Hemostats can stop bleeding due to their ability to clamp off blood vessels. They typically have ratchets to maintain a tight hold. Hemostats also have serrations at the tip of the instrument to secure the blood vessel in place. The tip may be straight or curved. Types of hemostats include: Mosquito hemostatic forceps have fine tips with serrations that run the
Mosquito hemostatic forceps (long) (Courtesy of Miltex, Inc.) entire length of the tip.
Kelly hemostatic forceps have serrations that only run partially up the tip. Mosquito forceps tips (Courtesy of Miltex, Inc.)
Kelly forceps (Courtesy of Integra/Jarit.)
Kelly forceps tips (Courtesy of Integra/Jarit.)
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TABLE 23-2 Instruments Used for Grasping and Clamping (continued) NAME OF INSTRUMENT
DESCRIPTION/INDICATIONS
Needle holders
Needle holders are used to grab and firmly hold a needle during the suturing process. The instrument contains ratchets and the tips are serrated.
Mayo-Hegar needle holder (Courtesty of Integra/Jarit.)
Image not available due to copyright restrictions
Towel clamps Jones towel clamp (Courtesy of Miltex, Inc.)
A towel clamp has two sharp tips and is used to hold a sterile towel in place during a surgical procedure. The handles are ratcheted to prevent slippage.
Backhaus towel clamp (Courtesy of Miltex, Inc.)
TABLE 23-3 Instruments to Improve Visualization NAME OF INSTRUMENT Dilators
Hegar uterine dilators: double end (Courtesy of Miltex, Inc.)
DESCRIPTION/INDICATIONS Dilators are double-ended smooth metal rods that have rounded tips and come in varying sizes. The purpose of the instrument is to dilate structures that are constricted, such as the urethra and cervix. Dilators have an array of calibrations ranging from small to large. The provider starts with the very smallest dilator and gradually works up to the dilator that is necessary to relieve the patient’s symptoms. Uterine dilators are designed to dilate the cervix, which may be constricted due to a buildup of scar tissue in the area or developmental abnormalities. They are also used to gain access into the uterus for examination purposes. Urethral dilators are used to stretch the urethra for the insertion of a scope or to dilate the urethra due to the presence of a stricture. continues
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TABLE 23-3 Instruments to Improve Visualization (continued) NAME OF INSTRUMENT
DESCRIPTION/INDICATIONS
Probes Uterine sound (Courtesy of Miltex, Inc.)
Probes are instruments that are used to explore wounds, body cavities, or hidden structures. A sound is a type of probe. It is a long instrument with calibrations that can be used to detect the size and shape of the area that is being probed. Uterine sounds are designed to facilitate the location of the cervical os, to dilate the cervix, and to determine uterine depth.
Van Buren urethral sounds (Courtesy of Miltex, Inc.)
Retractors
Urethral sounds are designed to measure the depth of the urethra and to help in the relief of a urethral stricture. A retractor is an instrument used to pull aside tissue to facilitate better visualization of an area that may be obstructed by other tissue. Retractors come in different sizes with different types of tips made up of single or multiple hooks for separating tissue.
Various kinds of retractors (Courtesy of Miltex, Inc.)
Scopes
Hirschman anoscope (Courtesy of Miltex, Inc.)
A scope is an illuminated instrument that is used to view an organ or body cavity. These are commonly used in exams, but may also be used during specific surgeries. Anoscopes are used to view the anus. Proctoscopes are used to view the anus and rectum.
Hirschman proctoscope (Courtesy of Miltex, Inc.)
Specula Graves vaginal speculum
Vienna nasal speculum
Graves vaginal speculum (Courtesy of Miltex, Inc.) Vienna nasal speculum (Courtesy of Miltex Inc.)
A speculum is an instrument that is used to increase the viewing area of a body cavity for examination purposes. Speculums may be metal or plastic and come in various sizes. Vaginal speculums are used to open the vagina. Nasal speculums increase the examination space of the nasal cavity.
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SOLUTIONS AND SUPPLIES USED FOR MINOR SURGERIES Along with instruments, other items are needed to perform minor office surgeries including solutions, drapes, sponges, culture swabs, biopsy containers, packing materials, suture material, and anesthetics. Medical assistants must know what items are necessary for each procedure and at what points each item is used prior to, during, and following the procedure.
Common Solutions Used in Minor Surgery There are only a few solutions used in minor office procedures. Typical solutions include liquids used to prep the patient’s skin and solutions used for irrigating purposes. The two most common solutions used during minor office procedures are sterile iodine and sterile saline. Table 23-4 lists a variety of solutions that are used during minor office surgeries and Figure 23-8 shows examples of these solutions.
Common Supplies Used in Minor Surgery There is a vast array of supplies that are used throughout surgical procedures. Some supplies will be placed directly on the surgical tray; however, many non-
FIGURE 23-8 A variety of solutions that may be used during minor office surgeries
instrument items used during a surgical procedure will be on a side table for easy retrieval. Table 23-5 lists common supplies used for office surgeries and their uses.
Common Anesthetics Used in Minor Surgery An anesthetic is used to produce a lack of feeling in patients during a surgical procedure. Anesthetics may be introduced into the body by way of injection, through intravenous routes (veins), topical routes
TABLE 23-4 Common Solutions Used in Minor Surgery SOLUTION
USES IN SURGERY
Betadine® (povidone-iodine)
For preparation of the skin prior to surgery Helps reduce bacteria that could potentially cause skin infection
Sterile saline
Used to flush and clean open wounds and to remove foreign particles from wounds
Isopropyl alcohol (isopropanol)
Used to disinfect skin; usually available in a 70% solution Also known as rubbing alcohol
Hibiclens® (chlorhexidine gluconate)
May be used as a skin antiseptic or skin cleanser during a surgical scrub Should be used sparingly, may be harsh on tissue if not used as directed
Hydrogen peroxide
Used as a mild antiseptic Has the ability to mechanically scrub moist skin or mucous membranes by oxidation Not being used as much today as in the past
Tincture of benzoin
Used to increase the adhesive capabilities of sterile adhesive skin closures (Steri-Strips®)
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TABLE 23-5 Common Supplies Used in Minor Surgery NAME OF INSTRUMENT
DESCRIPTION/INDICATIONS
Nonfenestrated sterile drapes or barriers
Sterile drapes are used to cover the surgical tray and parts of the patient during the procedure. These drapes are usually made of both cotton and polyester and contain a layer of plastic to make them water-resistant. They are available in a variety of different sizes to accommodate their many uses. The majority of surgical drapes will contain a dotted line signifying the outer one-inch border of the drape. This is the area of the drape that may be handled when removing the drape from the package and placing it onto the stand. This border is considered nonsterile.
Fenestrated drapes or barriers
Fenestrated drapes are made of the same materials as nonfenestrated drapes. The term fenestrated means to have one or more openings. A fenestrated drape has an opening that is placed over the surgical site once the skin has been prepped. It provides a working area for the provider.
Gauze pads (sponges): 2x2, 3x3, 4x4
Gauze pads or sponges may be used during or following surgical procedures. The pads are used to absorb blood and cleanse and dress wounds.
Sterile gloves, gown, and mask
Sterile gloves, a gown, and a mask (not pictured) are set out for the provider to put on prior to the start of the procedure.
Surgical wicks
Surgical wicks are used to remove small foreign bodies from the eye, ear, or wound. They are also used to instill a minute amount of solution to wounds, as well as to facilitate aspiration and drainage of fluids from wounds that would become infected if such fluids were allowed to lie within the tissue. (Boston Medical Products, Inc.)
Sterile packing material
(Curity is a trademark of Covidien AG or an affiliate. Reprinted with permission.)
Syringes/needles
Sterile packing material is usually packaged in long, sterile, cotton strips. The material may be plain or impregnated with a 5% iodoform solution. Iodoform is a crystalline iodine antiseptic that inhibits the growth of microorganisms. Special care must be taken when removing the strips from the container to maintain the sterility of both the strips and the container. The packing material may be used to pack wounds and may also be used to create a surgical wick. Sterile disposable needles and syringes are used to anesthetize the surgical area, as well as for irrigation purposes.
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TABLE 23-5 Common Supplies Used in Minor Surgery (continued) NAME OF INSTRUMENT
DESCRIPTION/INDICATIONS
Laboratory specimen containers
Laboratory specimen containers are filled with a tissue preservative and are used to transport tissue from a biopsy or lesion removal.
Laboratory culture transport tubes
Laboratory culture transport tubes are used when culturing a wound is necessary. They contain a preservative agar and a sterile swab.
Dressings and bandaging supplies
Bandaging supplies are needed to bandage affected areas following surgery.
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TOOL BOX
F IEL D S M A R T S
C R I T I C A L T H I N K I NG CHALLENGE
The contamination of sterile wicks or sterile packing material such as iodoform gauze may result in serious infection to the patient. You must take great measures to ensure the sterility of materials that are placed into an open wound or body cavity.
(skin), and through inhalation (respiratory tract). Four types of anesthetics are: ❖ General anesthetics, which place patients in a reversible loss of consciousness and are used during major surgical procedures. ❖ Local anesthetics, which are usually administered directly into subcutaneous tissue. Local anesthetics work by blocking sensory pain receptors at the
You are assisting the physician with packing a wound. The physician needs the entirety of the packing material from the bottle placed onto the sterile field. You notice that a piece of the packing material extends outside the dotted blue line. 1. What action should you take?
point of injection and in surrounding tissue. Local anesthetics are the most common type of anesthetic used during minor surgical procedures. All synthetic anesthetics end in the suffix “-caine” and may contain the additive epinephrine. Epinephrine helps to prolong the effect of the anesthetic. It is also a vasoconstrictor, which helps to reduce
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the amount of bleeding during the procedure. Manufacturers usually color-code the lettering on the labels of anesthetics according to the name and strength of the medication. Anesthetics with epinephrine may have red lettering or come with a red stripe on the label (Figure 23-9). Epinephrine is not normally used on small appendages such as the fingers, toes, nose, earlobes, or the penis. Because these appendages have a small surface area of tissue, there may be a delay in the blood vessels returning to their original diameter. The prolonged constriction may set the tissue up to become necrotic, thus leading to a sloughing of the tissue. Local anesthetics come in strengths of 0.5%, 1%, and 2%, and are available in vials, cartridges, or ampules. Before setting up a procedure, the medical assistant should ask the provider the following questions: ❖ What is the name and strength of the anesthetic desired? ❖ Should it contain epinephrine? ❖ Regional anesthetics, which are used when a large area of tissue needs to be blocked and requires infiltration of the anesthetic to the surrounding areas. This may be accomplished by using larger amounts of anesthetic or by injecting nerves adjacent to the nerve supplying the surgical site. ❖ Topical anesthetics, which are applied to the skin and work by deadening surface nerve endings in the areas to which they are applied. They may
FIGURE 23-9 Two vials of anesthetic (notice how the vial with epinephrine has red lettering and the vial without epinephrine has no red)
be applied prior to the introduction of a local anesthetic to reduce the stinging sensation caused by the insertion of the needle. Topical anesthetics may be in the form of liquids, gels, or sprays. Ethyl chloride, also known as “cold spray,” is a topical vapor coolant that may be sprayed onto skin to promote a temporary lack of feeling prior to the insertion of the needle. It only lasts for a few seconds, so the provider must work in an efficient manner. Ethyl chloride is flammable and should not be used prior to or during electrotherapy or laser procedures. Table 23-6 lists examples of different types of anesthetics.
Suture Materials The term suture may be used as either a noun or a verb. Used as a noun, it refers to the type of strand or fiber that is used to sew; used as a verb, it refers to the process of sewing. The purpose of a suture is to hold the edges of a wound together until the natural healing process joins the tissue permanently. Suturing promotes faster healing and lessens scaring. The term ligature means tying, and is the term that is used when referencing suture material that is used to tie off tubular structures such as the fallopian tubes or vas deferens. The quality of suture material is judged by its tensile strength (the amount of weight necessary to break it divided by its cross-sectional area), its ability to hold a knot, its ability to expand during times of swelling, its ability to recoil to its original size after much handling, and its tissue reactivity. Suture materials and needles (Figure 23-10) are usually selected based on the type of tissue to be sutured and the length of time necessary for healing to take place. There are two types of suture material: absorbable, which is used most often for internal structures, and nonabsorbable, which is usually used on external structures; however, nonabsorbable sutures may also be used to tie off certain structures internally. Suture material comes in various sizes and lengths to accommodate the needs of the provider.
Absorbable Suture Material Absorbable suture material is used when suturing deeper layers of the skin or when suturing structures that are difficult to reach. This type of suture material is absorbed by the body’s tissues, and thus does not require manual removal. One of the first absorbable suture materials was referred to as surgical gut or “catgut,” and was made from tissue taken from sheep intestines. Catgut suture material may be plain or coated
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TABLE 23-6 Common Anesthetics Used in Minor Surgery NAME OF ANESTHETIC
DESCRIPTION/INDICATION
Marcaine (bupivacaine)
Long-acting anesthetic Used for local infiltration or nerve blocks
Xylocaine (lidocaine HCL)
Local or regional anesthesia administered by infiltration May contain epinephrine to reduce bleeding through vasoconstriction Most commonly used local anesthetic
Novocaine (procaine HCL)
Oldest injectable anesthetic Used primarily in dentistry Cocaine derivative Has vasoconstriction properties
Carbocaine (mepivacaine HCL) Injectable local anesthetic Effective for a longer period of time than lidocaine Epineprine (adjunct to other anesthetics)
Used as an adjunct to lidocaine Acts as a vasoconstrictor to reduce bleeding
Ethyl chloride
An aerosol product that causes temporary relief from pain by cooling the skin Not commonly used due to EPA regulations of aerosols
Nitrous oxide
Administered by inhalation Commonly used during dental procedures Gives a feeling of euphoria
Nonabsorbable Suture Material Nonabsorbable suture material is the most common type of suture material used in medical office procedures because it is designed for suturing external structures. Examples of nonabsorbable suture material include silk, nylon, dacron, and prolene. Always check the provider’s preference prior to setting up the surgical tray.
Suture Sizing Suture sizes are determined by the diameter of the suture. The smallest is 6-0 (000000) and is used in cosmetic procedures. Suture sizes 5-0 (00000) and 4-0 (0000) are larger and used primarily on the trunk and extremities. Thick skin may require closure with a size 3-0. Larger diameter sutures (1-0 through 2-0) are generally not used for skin closures. FIGURE 23-10 A variety of suture packs
Suture Needles with chromium salts, which helps to delay the absorption process and allows more time for healing. Coated catgut suture material is referred to as chromium gut. Today, catgut suture material is rarely used; it has been replaced by synthetic forms of absorbable material that provide much longer absorption rates and cause less irritation (refer to Table 23-7 for examples).
Suture needles are used to close wounds and come in a variety of sizes and shapes. Atraumatic needles or swaged needles are packaged with suture material fused to an eyeless needle. These types of needles cause less tissue damage than traumatic needles. Traumatic needles, or eyed needles, are packaged so that the needle is separate from the suture material, and require the person performing the suturing to thread the needle.
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TABLE 23-7 Types of Suture Material TYPE
ABSORBABLE
NATURAL/ SYNTHETIC
AVAILABLE SIZES
Polyglycolic acid (Dexon)
Yes
Synthetic
2-0, 3-0, 4-0, 5-0, 6-0
Polyglactin (Vicryl)
Yes (complete after 70 days)
Synthetic
2-0, 3-0, 4-0, 5-0, 6-0
Polydioxanone (PS II)
Yes (complete after 180 days)
Synthetic
2-0, 3-0, 4-0, 5-0, 6-0
Polyglyconate (Maxon)
Yes
Synthetic
2-0, 3-0, 4-0, 5-0, 6-0
Polyamide (Nylon)
No
Synthetic
2-0, 3-0, 4-0, 5-0, 6-0
Polyester (Dacron)
No
Synthetic
2-0, 3-0, 4-0, 5-0, 6-0
Polypropylene (Prolene)
No
Synthetic
2-0, 3-0, 4-0, 5-0, 6-0
Catgut
Yes
Natural
3-0, 4-0, 5-0, 9-0
Silk
No
Natural
2-0, 3-0, 4-0, 5-0, 6-0
Suture needles may be straight or curved, allowing the needle to penetrate deeper tissue. The size and shape of the needle selected is determined by the structure to be sutured. Cosmetic procedures usually require the use of a smaller needle, while noncosmetic structures use larger needles (see Figure 23-11 for a variety of suture needles).
FIGURE 23-11 Curved and straight suture needles Straight
1/ 4 3/ 8
Circle
Other Supplies Used to Close the Skin There are other methods that are used to close the skin following surgical procedures or an injury, including the insertion of surgical staples and the application of sterile adhesive skin closurse and surgical glues. The method of selection is based on several factors including the age of the patient, the location of the wound, the depth of the wound, and the personal preference of the provider.
Skin Staples Surgical staples (Figure 23-12) are introduced in the skin by using a surgical stapler. The stapler comes with a cartridge that contains a specific size and number of staples. The stapler may be disposable (designed for
Circle
FIGURE 23-12 An example of surgical staples
1/ 2
5/ 8
Circle
Circle
Curved
Eyed needles
Swaged needle
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one time use) or reusable. Advantages of using staples are that they are quickly inserted, are more economical than sutures, and cause fewer infections because the skin does not have to be handled as much as it does during suturing procedures. Disadvantages of staples may include permanent scars if used inappropriately and imperfect aligning of the wound edges.
Sterile Skin Closures Medical assistants may be responsible for the application of sterile skin closures. The application of skin closures may be indicated for wounds that are not very deep. The nonallergic adhesive strips are used to approximate the edges of a slightly gaping wound. Benefits of applying adhesive skin closures include the following: ❖ ❖ ❖ ❖ ❖
No local anesthetic needed. Much more time efficient than applying sutures More cost efficient than sutures Less scarring Reduced risk of infection
Adhesive closures come in a variety of widths and lengths and may be cut with a pair of sterile scissors for exact sizing. Refer to Procedure 23-1 for complete instructions on how to apply sterile adhesive strips.
TYPES OF PROCEDURES PERFORMED IN THE MEDICAL OFFICE/TRAY SETUPS In today’s world of ambulatory medicine, providers perform quite an array of minor surgical procedures. Many of these procedures only require the use of specific instruments and surgical supplies; however, with the advancement of technology, office surgeries have expanded to incorporate the use of advanced technological equipment, including the use of electrosurgical equipment and lasers. Chemicals may also be used to destroy unwanted growths or cauterize tissue. The medical assistant should memorize the items that are necessary for particular procedures and become familiar with special chemicals and equipment used during these procedures.
Surgical Adhesives or Surgical Glue Surgical adhesives are now used in place of sutures and staples by providers working in trauma, plastic surgery, and pediatrics. The sealants in these products provide the incision site with instant strength usually within a matter of minutes from the time of application. Benefits of using surgical adhesives include the following:
❖ ❖ ❖ ❖ ❖
TOOL BOX
PA TIEN T P E R SP E C T I V E I don’t know if I want the physician to close my incision with glue. What happens if they close the skin incorrectly? Am I going to have an ugly scar?
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A drawback to some surgical glue is the inability to straighten out tissue that was not closed correctly. Some surgical adhesives allow the provider a window of time to make adjustments before the glue hardens. As manufacturers perfect these products, their popularity will increase.
Procedures That Require No Special Equipment
❖ Less pain (no anesthetizing needles are necessary) ❖ Good cosmetic results (no stitch marks) ❖ Less chance of infection, because a needle is not pulled back and forth through flaps of skin ❖ No need for a follow-up visit to have sutures or staples removed
❖
Common minor surgical procedures that do not require special equipment include: Laceration repairs Excision of a sebaceous cyst Aspiration of fluid from a joint Incision and drainage procedures Suture/staple removal
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C R I T I C A L T H I N K I NG CHALLENGE Refer to the Patient Perspective tool box on this page. 1. What type of reassurance can you give the patient to make the patient feel a little better about using surgical glue in lieu of sutures? 2. Should you share the patient’s fears with the physician?
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Laceration Repairs A laceration is a jagged wound or cut that may be the result of a traumatic injury. Any time the patient presents with a laceration that is gaping, the medical assistant should prepare for a laceration repair. Table 23-8 lists items that are necessary for a laceration repair. Whether sutures or other materials such as surgical staples, adhesives, or sterile skin closures will be used depends on the provider. The medical assistant should check with the provider prior to setting up the tray. The medical assistant should also check the date of the patient’s last tetanus shot. If the time since the last shot is more than 10 years, the medical assistant should be prepared to administer the vaccine following an order from the provider.
Excision of a Sebaceous Cyst A sebaceous cyst is a cyst that occurs as the result of a blocked sebaceous gland. Sebaceous glands are responsible for producing sebum, or the oil that helps to keep the skin moisturized. When a patient has a sebaceous cyst, the gland continues to secrete sebum but because the gland is blocked, it forms a capsule and fills with a thick, cheesy-looking, odiferous material. These cysts are usually very painful and become more painful as they grow. Often times the area becomes infected, making their removal much more complicated. Sebaceous cysts are benign and occur frequently on the face, ears, neck, scalp, or back. If the area appears to be infected, the provider may try to drain the cyst and place the patient on antibiotic therapy. Once the infection clears, the provider will then try to completely remove the cyst. Table 23-9 lists items that are necessary for cyst removal. The medical assistant should be prepared to receive the cyst by holding out a specimen container so that
it may be sent out for identification purposes. Patients may be placed on antibiotic therapy following excision to decrease their risk of infection.
Aspiration of Fluid from a Joint A common type of surgery performed on patients who have arthritis or old sports injuries is joint aspiration, or removal of excess fluid that builds up as a result of inflammation. The knee is the most common area of the body where this procedure is performed. The fluid may be sent out for microscopic examination or for culturing purposes. The patient usually receives a combination long-term anesthetic and steroid injection to provide long-term relief. Patients often return in three months to a year to have this procedure repeated, and are placed on antibiotic/anti-inflammatory therapy following the procedure. Table 23-10 lists items necessary for this procedure.
Assisting with an Incision and Drainage Procedure An incision and drainage procedure is routinely performed on patients who have an abscess or a localized infection. An abscess walls off a localized infection to keep it from spreading to other areas of the body. Furuncles (which is another name for boils) will also often need to be incised and drained. The provider will lance the area using a sterile scalpel and will place either a rubber Penrose drain or gauze wick into the wound to keep the edges of the wound pulled apart so the wound may continue to drain. The patient’s wound is dressed with several sterile 4x4s to accommodate the drainage. The patient is usually placed on antibiotics and will return to have the packing material removed at a later date. Table 23-11 lists items necessary for this procedure.
TABLE 23-8 Items for a Laceration Repair ITEMS PLACED DIRECTLY ON THE STERILE FIELD
ITEMS PLACED ON A SIDE TABLE
Sterile drapes
Sterile gloves
Needle holder
Bandage scissors
Appropriate suture material
Bandage material (gauze, tape, rolled gauze)
Surgical scissors
Antiseptic solution
Tissue forceps
Sterile water or saline
Sterile gauze pads
Appropriate anesthetic
Needle/syringe
Appropriate PPE
Two sterile cups or basins
Triple antibiotic cream/ointment Cotton-tipped applicators Biohazard and sharps containers
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TABLE 23-9 Items for a Sebaceous Cyst Removal ITEMS PLACED DIRECTLY ON THE STERILE FIELD
ITEMS PLACED ON A SIDE TABLE
Sterile drapes
Appropriate PPE
Syringe and needle
Sterile gloves
Scalpel blade and handle
Anesthetic/alcohol wipe
Needle holder
Packing gauze (optional)
Appropriate suture material
Specimen container/lab form
Iris scissors
Sterile bandaging material
Hemostatic forceps
Antiseptic solution
Sterile gauze
Sterile water or saline
Hemostats (optional)
Biohazard and sharps containers
Suture material Two sterile cups or basins
TABLE 23-10 Items for a Joint Aspiration Tray ITEMS PLACED DIRECTLY ON THE STERILE FIELD
ITEMS PLACED ON A SIDE TABLE
Sterile drapes
Appropriate PPE
Syringe and needle
Sterile gloves
Aspiration needle
Anesthetic
Hemostat
Specimen container/culture transfer tube
Sterile gauze
Sterile bandaging material
Two sterile cups or basins
Antiseptic solution Sterile saline or water Biohazard and sharps containers
TABLE 23-11 Items Needed for an Incision and Drainage Procedure ITEMS PLACED DIRECTLY ON THE STERILE FIELD
ITEMS PLACED ON A SIDE TABLE
Syringe and needle
Appropriate PPE
Scalpel blade and handle
Sterile gloves
Tissue forceps
Appropriate anesthetic
Sterile drapes
Packing gauze (iodoform or plain)
Dissecting scissors/hemostat
Sterile bandaging material
Sterile gauze
Penrose drain (up to the provider)
Two sterile cups or basins
Antiseptic solution Sterile saline or water Culture medium Biohazard and sharps containers
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The medical assistant will instruct the patient on the procedure for changing the dressing and packing.
Procedures That Require the Use of Special Equipment, Lasers, or Chemicals
Suture/Staple Removal
Providers may use many other resources to help them perform surgical procedures in the office. The equipment that is used will be based on the type of procedure to be performed, equipment availability, and the provider’s preference. The medical assistant will always need to check with the provider for clarification when working with new providers. Some of the different equipment used during surgical procedures include:
Patients may have sutures or staples inserted while in the hospital but will often return to their general practitioner’s or surgeon’s office to have them removed. The medical assistant may be responsible for performing this very important task. It will be important for the medical assistant to examine the wound closely and look for signs of gaping or infection. Examine both the bandage and the suture area following the removal of the bandage. Does the bandage look dirty, tattered, or wet, or does it contain drainage that is consistent with infection? Does the wound look like it is entirely closed, and is there good approximation of the edges of the wound? Are there any signs of infection on the tissue surrounding the wound such as erythema, warmth, or edema? If the bandage appears to be stuck to the wound, the medical assistant may need to saturate the dressing with sterile saline prior to removal. Always pull the edges of the dressing toward the wound. The medical assistant should not remove any sutures or staples until the provider has had an opportunity to inspect the wound area. The average time spans in which sutures are removed are: ❖ ❖ ❖ ❖ ❖
Scalp: 7 to 10 days Face: 3 to 5 days Arms and legs: 10 to 14 days Trunk: 7 to 10 days Joints: 14 days
The items that are necessary for suture removal are listed in Table 23-12. For surgical staple removal, use all items as listed but substitute a surgical staple remover in place of suture scissors. Refer to Procedure 23-2 for complete instructions on removing sutures and staples.
❖ Electrical surgical/cautery units ❖ Laser instruments ❖ Liquid chemicals
Procedures Using Electrical Current Electrosurgical procedures are performed to destroy benign and malignant lesions, to cut or excise tissue, and to control bleeding. Dermatologists frequently perform these procedures, but other types of providers may also be certified to use electrosurgical equipment. Electrosurgery is useful for treating different types of skin lesions such as skin tags and small angiomas (benign tumors consisting of blood vessels). Types of electrosurgery include electrodesiccation, electrofulguration, electrocoagulation, and electrosection. In electrodesiccation, the electrode from the electrosurgical unit touches the skin to stimulate tissue destruction and is frequently performed to treat spider angiomas, warts, and polyps. Electrofulguration is used when working with more shallow tissues. The electrode does not touch the skin directly, but instead is held 1 to 2 millimeters away from the skin to produce a sparking sensation. This technique is used to remove polyps and cancer cells. In electrosection, the tip of the electrode is shaped like a fine needle, a wire loop, or a triangle and is used to incise or cut tissue for the removal of a specimen. Electrocoagulation is used to clot small
TABLE 23-12 Suture or Staple Removal Tray ITEMS PLACED DIRECTLY ON THE STERILE FIELD
ITEMS PLACED ON A SIDE TABLE
Sterile suture removal scissors
PPE
Sterile dressing forceps
Sterile saline/skin antiseptic
Sterile bowl
Bandaging supplies
Sterile gauze pads
Triple antibiotic cream or ointment (if ordered) Biohazard container
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blood vessels to help control bleeding during minor office procedures. Electrosurgical units (Figure 23-13) come with interchangeable electrodes to help create the proper modality required for the procedure being performed. Table 23-13 lists items that are necessary for electrosurgical procedures.
Laser Procedures The term laser is the acronym for “light amplification by stimulated emission of radiation.” Lasers are instruments that use a powerful, high-focused beam of light to remove unwanted tissue and to control bleeding in a variety of invasive and noninvasive procedures. There are many types of lasers, and each laser instrument is designed to perform a specific procedure. Lasers used in minor office procedures are typically designed to destroy old tissue by producing a beam that that can focus directly on its target without hurting surrounding tissue. This technique may be referred to as laser resurfacing and is used to remove the outer layers of skin to help minimize the appearance of wrinkles and fine scars. Lasers can also act as a small scalpel by cutting through tissue in a very precise manner. They may also be used to reattach detached retinas and burn away ulcers. Because lasers are dangerous, health care personnel should follow safe practice standards when exposed to lasers. Safe practices include: 1. Having equipment checked on a regular basis to make certain that it is in good working order; otherwise, the laser could cause severe burns to the patient and persons administering the treatment 2. Posting a special plaque in the entryway of the room where laser is being used to warn those on the outside that the laser is in use
FIGURE 23-13 An electrocautery unit
3. Pulling blinds prior to working with lasers to help keep out stray light 4. Removing any items in the way of the beam that could possibly ignite such as paper products and nondisposable sheets and gowns 5. Making sure all personnel (including the provider) wear safety goggles when using laser instruments. The patient should also wear safety glasses when applicable. 6. Having sterile water accessible just in case the heat from the laser causes cloth or paper to ignite
TABLE 23-13 Electrosurgical Tray ITEMS PLACED DIRECTLY ON THE STERILE FIELD
ITEMS PLACED ON A SIDE
Needle and syringe
PPE
Sterile gauze pads
Antiseptic solution/sterile saline
Cautery needles
Electrosurgical unit
Bovie pads
Disposable tips
Two sterile cups or basins
Specimen container Sterile gloves Triple antibiotic cream/ointment Gauze/tape Biohazard and sharps containers
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7. Having patients wear a mouth guard when using lasers in the mouth area to protect their fillings, crowns, and bridges 8. Checking the package insert to determine how the skin should be prepped when working with lasers. If alcohol is used, it should be completely dried to avoid setting off a spark from the lasers. Assisting with the Laser Procedure The medical assistant should prepare the area following all of the safety tips above. The laser instrument, gauze, and sterile water should be readily accessible. Responsibilities during the procedure include assisting the provider with the anesthetic and holding the adjoining vacuum hose to clear away vaporized tissue. The medical assistant may also be asked to help control excess bleeding during the procedure. Table 23-14 lists items necessary for laser surgery.
Cryosurgery Cryosurgery is a procedure in which unwanted tissue, such as skin lesions and warts, is destroyed by
freezing the tissue. Cryosurgery, also known as cryotherapy, may involve the use of liquid nitrogen, which is typically stored in a large canister. The liquid nitrogen is usually removed from the large canister and placed into a thermos before taking it into the examination or surgery room. Liquid nitrogen may be used on any lesion on the skin, hemorrhoids, the cervix, and the retina in rare situations. It may also be used to destroy the prostate gland. For smaller skin lesions, the provider may apply liquid nitrogen to the area using a cotton tip applicator. Liquid nitrogen is also available in a pressurized can, which allows the liquid nitrogen to be sprayed over the affected area for easy application. Patients should be instructed that they may feel a little discomfort during the procedure, but the pain usually goes away fairly quickly. The patient may feel a cold sensation followed by a burning sensation while the procedure is being performed. The patient should be informed that more than one application may be necessary.
TABLE 23-14 Laser Surgery Tray ITEMS PLACED DIRECTLY ON THE STERILE FIELD
ITEMS PLACED ON A SIDE TABLE
Sterile gauze
PPE
Sterile water (in sterile container)
Anesthetic Sterile syringe and needle Safety goggles for everyone involved in the procedure. Laser instrument/tips Biohazardous waste container
PROCEDURE 23-1 Apply Skin Closures Objective: To properly close a wound with adhesive strips.
Equipment/Supplies: ❖ Sterile 4x4s ❖ Skin antiseptic swabs ❖ Adhesive strips or closures (sized to match the patient’s wound) ❖ Tincture of benzoin
❖ ❖ ❖ ❖ ❖
Sterile cotton tip applicators Pair of sterile gloves Bandaging material Biohazard waste container Patient’s chart
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PROCEDURAL STEPS
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RATIONALE
1. Wash your hands and gather the supplies. 2. Identify the patient using two identifiers, identify yourself, and explain the procedure. Make certain that the patient is not allergic to adhesive.
If patient is allergic to adhesive, applying the strips could cause the patient to have an allergic reaction.
3. Inspect the wound and select the size of adhesive strips that best matches the patient’s wound.
This will make application easier and will avoid excess that has to be cut.
4. Position the patient so he is comfortable and position the tray for easy access. 5. Clean the tray and set up the necessary items: 2 peel-apart 4x4 sponge pads 1 pack of skin antiseptic swabs 2 peel-apart cotton tip applicators 1 bottle of tincture of benzoin 1 package of sterile adhesive strips. Open all items in a sterile fashion so that they are completely open for easy access. 6. Wash your hands and apply sterile gloves. 7. Clean the patient’s skin so that the cleansing extends at least 2 to 3 inches (5 to 7 cm) around the wound using sterile antiseptic swabs.
This helps to remove any debris, blood, or skin oils, and prevent infection.
8. Allow the area to completely dry.
The area must be completely dry for best results.
9. Remove gloves and wash your hands. 10. Apply a thin coat of tincture of benzoin to the periphery of the wound using a new sterile cotton tip applicator for each side. Do not allow the tincture of benzoin to touch the wound.
The tincture of benzoin will help the strips to adhere to the skin.
11. Follow the manufacturer’s instructions for removing the strips.
Some manufacturers have a numbering and color-code system that walks you through the removal and application of strips. This will vary from one manufacturer to another.
12. If applying single strips, line the first strip up with the center of the wound (Figure 23-14). Firmly press one end of the strip on either side of the wound to secure it in place. 13. Gently stretch the strip while lining up both edges of the wound so that they come together. (You may need to use the other hand to help oppose the wound edges.) 14. Once the skin is lined up evenly on both sides, pull the tape to the opposite side while pressing down firmly on the skin.
The wound edges must come together evenly to heal properly and minimize scarring. FIGURE 23-14 Apply the first strip to the center of the wound.
15. Apply the next strip approximately 1⁄8 inch from the first strip on either side of the first strip. continues
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PROCEDURAL STEPS
RATIONALE
16. Perform the same step on the opposite side of the wound. 17. Continue this process until the wound is completely closed. 18. If needed, apply one closure approximately 1⁄ inch away from the strip’s edges, running 2 parallel to the wound on either side of the strips (Figure 23-15).
This helps to secure the adhesive strips. FIGURE 23-15
19. Make certain that there is good approximation of the wound.
Add parallel closures for additional support.
20. Apply dressing if necessary. 21. Remove gloves and wash your hands. 22. Give the patient home care instructions.
It is important for the patient to know how to properly care for the wound and the strips to avoid complications.
23. Document the procedure in the chart.
Document the date and time, the procedure itself and the location of the procedure and how many strips were applied. List what type of dressing was applied and any home care instructions given to the patient. Always show the provider’s order.
DOCUMENTATION EXAMPLE:
10-12-XX 2:30 p.m.
Steri-strip application x 6 to pt’s R. forearm per Dr. Kennedy. Cleaned surrounding area with iodine swabs. Applied tincture of benzoin and applied the strips. Good approximation of wound. Closed spiral dressing applied. Gave pt home care instructions. Pt. to return in 5 days. Pt instructed to call if there are any concerns or complications. Chloe Brady CMA (AAMA)
PROCEDURE 23-2 Suture or Staple Removal Objective: To correctly remove sutures or staples without contaminating internal tissue or causing further injury to the patient.
Equipment/Supplies: ❖ Suture removal kit (suture scissors and thumb forceps) or staple removal kit (staple remover and thumb forceps) ❖ Bandage scissors ❖ Sterile 4x4s ❖ Sterile saline/skin antiseptic
❖ ❖ ❖ ❖ ❖ ❖
Sterile container Sterile gloves/examination gloves Biohazard waste container Dressing supplies Antibiotic cream (if ordered by provider) Patient’s chart
I N S T R U M E N T I D E N T I F I C AT IO N A N D T R AY S E T U P S
PROCEDURAL STEPS
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RATIONALE
1. Identify the patient using two identifiers. 2. Identify yourself and explain the procedure.
Explaining the procedure will help the patient know what to expect.
3. Ask if the patient took all of the antibiotic and whether all other home care instructions were followed.
It is important to make certain that the patient has been compliant. A lack of compliance may lead to infection.
4. Examine the outside of the patient’s bandage and make a mental note.
The condition of the bandage will help to determine if the patient has been following home care instructions.
5. Wash your hands and apply examination gloves. 6. Remove the dressing and observe both the inside of the dressing and the wound area for any signs of infection (make a mental note).
Examination of the dressing and the wound addresses any compliance or infection concerns.
7. Discard the dressing into the biohazard container, remove gloves, and wash your hands.
If exudates are present, the dressing should be discarded into biohazard container.
8. Have the provider observe the wound before starting the procedure.
It is important for the provider to inspect the wound for satisfactory approximation of the wound.
9. Once the provider okays the procedure, apply a waterproof drape underneath the patient’s wound.
This is only in cases where the wound may need to be irrigated because of dried exudate.
10. Set up a sterile tray.
Use sterile technique just in case the wound has any gaps prior to or following suture or staple removal.
11. Pour sterile saline into a sterile container. 12. Apply sterile gloves. 13. If the sutures are adhered to the skin due to dried blood and other secretions, irrigate the wound according to the provider’s instructions. Otherwise, cleanse area with a skin antiseptic.
This will loosen the sutures, making them easier to remove.
14. If removing sutures, grasp one side of the first knot with the thumb forceps and gently tug upward on the end of the knot. Using the other hand, work the suture scissors under the knot as close to the skin as possible and cut the suture (Figure 23-16a). Pull the knot toward the wound, making certain that no part of the suture that was on the outside goes through the inside of the wound (Figure 23-16b). If removing staples, gently grasp the staple with the remover and squeeze the handle of the staple remover until the staple is pinched up and out.
Do not let any part of the suture that was on the outside of the skin go back through the inside of the skin; it may cause infection.
FIGURE 23-16a Pull up on one side of the knot and cut the suture as close to the skin as possible.
15. Continue to remove the sutures or staples until all have been removed. 16. Make sure that the wound still has good approximation and that there is no gapping of the skin (notify the provider if there are any concerns).
If the wound starts to gap at any time during removal, notify the provider before proceeding any further. The wound may not be as healed as originally thought.
FIGURE 23-16b Remove the sutures by pulling toward the incision.
continues
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17. Apply antiseptic cream if ordered and dress the wound according to the provider’s instructions. 18. Remove gloves and wash your hands. 19. Give the patient any home care instructions and dismiss.
There usually are no home care instructions if the wound is completely closed.
20. Clean the area and dispose of related items in the biohazardous trash receptacle. 21. Document the procedure.
DOCUMENTATION EXAMPLE:
12-12-XX 6:30 p.m.
Pt. here to have sutures removed from L. foot. Removed bandage and inspected wound. No exudates on bandage or coming from the wound, –erythema, –edema. Dr. Miller inspected wound and gave v/o to remove sutures. Removed all sutures (6 total). Good closure of wound following removal. Dressed site with adhesive bandage. Instructed pt to remove bandage tomorrow and to call with any concerns. Scheduled pt for a F/U appt. on 2-18-XX Destiny Green, CMA (AAMA)
Chapter Summary There are many procedures performed in the medical office. Medical assistants must be able to identify common instruments used in ambulatory care centers and must be familiar with other supplies and equipment used during minor office surgeries. Memorizing items necessary for each type of tray setup will expedite setting up trays and setting up the room for ambulatory surgical procedures and improve the worth of the medical assistant.
FIELD APPLICATION CHALLENGE You are setting up for a special foot surgery. You place all of the necessary items on their appropriate tray or side table. The physician requested that you draw up a syringe with 4 cc of Lidocaine 1% without epinephrine. You are not in the room with the physician when he anesthetizes the patient, but you return to the room shortly thereafter. You notice that the label on the vial reads Lidocaine 1% with epinephrine. You recall that the physician ordered the Lidocaine without epinephrine. 1. What type of color coding on the vial should have alerted you that you had the wrong anesthetic?
2. The medication has already been given and the physician has started the procedure. What should be your next course of action? After all, it is the right anesthetic and right strength, the only difference in the order is that the anesthetic contains epinephrine. 3. What would be a more accepted procedure for drawing up the anesthetic?
I N S T R U M E N T I D E N T I F I C AT IO N A N D T R AY S E T U P S
Chapter Assessment 1. The type of handle that opens and closes by pinching and releasing is known as a: a. ring handle. b. thumb handle. c. pinch and release handle. d. all of the above. 2. What is the part of an instrument that is hinged and found on a ring-handled instrument that contain ratchets? a. Jaws b. Shanks c. Box lock d. Ratchet 3. What surgical instrument is shaped like a spoon or loop and is used to scrape and remove tissue from the skin or body cavity? a. Curette b. Surgical spoon c. Sound d. Forceps 4. Which of the following solutions would not typically be used during minor office surgery? a. Sterile saline b. Povidone iodine c. Isopropyl alcohol d. Distilled water 5. Which of the following helps to prolong the effects of an anesthetic agent? a. Epinephrine b. Norepinephrine c. ACTH d. Corphrine 6. All of the following are anesthetic agents commonly used in the medical office except: a. Xylocaine. b. Procaine. c. Lidocaine. d. ether. 7. Which type of suture material is used in deeper tissues? a. Synthetic b. Absorbable c. Nonabsorbable d. Nylon
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8. Which of the following techniques is used to remove fluid from a joint? a. Arthroscopy b. Aspiration c. Incision and drainage d. None of the above 9. Which of the following suture materials would have the largest diameter? a. 3-0 b. 4-0 c. 5-0 d. 6-0 10. Which of the following surgical techniques involves the use of liquid nitrogen? a. Electrosurgery b. Laser c. Cautery d. Cryosurgery
Web Activities 1. Go online and type the following words into a search engine: Surgical adhesives for wound closure. Select an article that provides you with answers to the following questions: a. What are three benefits to using surgical adhesives? b. What types of wounds or surgeries are best for surgical adhesives? c. What is one downfall for using surgical adhesives? 2. Go online and price a set of Hegar uterine dilators from at least two different manufacturers and answer the following questions: a. What are the names of the two different manufacturers? b. Which manufacturer had the lowest price? c. Was there any difference in the instrument from one manufacturer to the other?
CONNECTION Using your StudyWARE CD-ROM: ❖ Complete the Crossword Puzzle activity for this chapter. ❖ Complete the Quiz for this chapter in Test Mode.
C H A P T E R
Assisting with Minor Office Surgeries and Wound Care Procedures Chapter Outline Developing a Sterile Conscience Patient Safety Considerations Preparing for Office Surgeries Setup Procedures Once the Patient Enters the Surgical Suite Performing a Surgical Handwash and Applying Surgical Attire
Assisting the Physician before and during the Procedure Pre-Procedure Tasks During the Procedure At the Conclusion of the Surgery Wound Care Stages of Wound Healing Today’s Wound Care Philosophy Types of Dressings Types of Bandage Material Wound Care Alternatives
24 Essential Terms bandage closed wound concentric circle debridement dressing exudate hyperbaric oxygen (HBO2) therapy open wound primary dressing purulent sanguineous secondary dressing serosanguineous serous sterile conscience subatmospheric pressure device
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KEY COMPETENCIES
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CAAHEP
ABHES
Perform a Surgical Handwash and Apply Surgical Gloves
III.C.3.b.1.a
VI.A.1.a.4.c
Prepare the Patient’s Skin for the Surgical Procedure
III.C.3.b.4.f
VI.A.1.a.4.b
Disinfect a Surgical Tray and Place a Sterile Barrier on the Tray
III.C.3.b.4.f
VI.A.1.a.4.c
Open Sterile Items and Place Them on the Sterile Field
III.C.3.b.4.f
VI.A.1.a.4.c
Set Up a Complete Sterile Tray and Pour a Sterile Solution
III.C.3.b.4.f
VI.A.1.a.4.c
Apply Surgical Attire
III.C.3.b.4.f
VI.A.1.a.4.c
Remove Old Dressing, Irrigate the Wound, and Apply of a New Dressing
III.C.3.b.1.d III.C.3.b.1.e
VI.A.1.a.4.c
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Developmental Objectives After completing this chapter, you should be able to: 1. Correctly spell and define the essential terms. 2. List and describe the different guidelines for developing aseptic technique. 3. Describe how a sterile conscience will help to reduce the patient’s risk of developing a postop infection. 4. List common procedures that are performed prior to, during, and following the surgical procedure. 5. List common preparation instructions given to patients prior to the procedure and common home care instructions given to the patients for most surgical procedures. 6. List the proper technique for preparing a Mayo stand for a surgical procedure. 7. List and describe how to place wrapped items and peel-apart items onto the sterile field. 8. List and describe the proper procedure for pouring solutions into a container on the sterile field. 9. Define the three stages of healing and describe interferences that can impede the healing process. 10. Compare and contrast the different types of dressings used in health care and describe when each type would be used. 11. Compare and contrast two different types of alternative treatments used to treat chronic wounds that will not heal.
Introduction There are a multitude of tasks that must be completed when preparing for and assisting with minor office surgeries. The procedures for sanitizing and processing instruments were presented in Chapter 22. Chapter 23 presented information
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regarding common supplies, solutions, and instruments that are used during various types of surgeries. This chapter will present important information on preparing patients for surgical procedures, preparing the surgical suite, and assisting the physician during the procedure. Postsurgical and wound care responsibilities are additional topics presented in the chapter.
DEVELOPING A STERILE CONSCIENCE Chapter 22 introduced the guidelines for practicing medical and surgical asepsis. This chapter will incorporate those principles and will build on aseptic technique, particularly in the surgical suite. Surgical technicians must develop a “sterile conscience” in order to be successful in their careers. Medical assistants working in ambulatory surgery should also develop a sterile conscience. A sterile conscience is a mindset of constant vigilance. It is taking ownership for the sterility of items from the time of processing through the termination of the procedure. It involves keeping a watchful eye on the surgical tray, surgical site, and other personnel during the surgical procedure, and putting the patient’s best interests above personal interests when sterility is compromised, regardless of the outcome. In order to develop a sterile conscience, one must know general guidelines for instituting aseptic technique: 1. Remove lab coats and any other clothing that could potentially drag across the field, and pull hair back prior to setting up a sterile tray. 2. Traffic in the suite should be kept to a minimum. 3. Items are either sterile or nonsterile—there is no in-between. If something occurs that makes you question if an item is sterile, treat it as though it is contaminated. (“When in doubt, get it out!”) 4. Trays with surgical drapes are only considered sterile if they are at table height or waist level. 5. Handle packs and drapes as little as possible to avoid contamination. Avoid adjusting or moving drapes once in place as this could cause contamination. 6. Do not set up the tray until just before the physician enters the room. 7. Always stand so that your body is several inches away from the tray when setting up a sterile field, and never reach across a sterile field.
8. The outer 1 inch diameter around any sterile drape is considered nonsterile. 9. Never drop items directly over the field. Stand back a few inches and make certain that there is always a sterile barrier between your hands and the sterile field. 10. Do not toss or flip items onto the field. This can cause air currents to travel across the field. 11. Solution containers should be placed at the corner of the tray, and solutions should be poured at a distance of 2 to 6 inches above the solution container. 12. Always approach a sterile tray or a scrubbed person head-on, and do not walk between two sterile fields. 13. Never leave a sterile tray unattended. 14. Once a sterile item or drape becomes wet, it should be considered contaminated unless there is a waterproof drape underneath. 15. Scrubbed personnel should never allow their hands to drop below their waist and should clasp their hands together when not using them. 16. Avoid talking, coughing, sneezing, or laughing when setting up the surgical tray or assisting the physician.
PATIENT SAFETY CONSIDERATIONS There are many patient safety concerns associated with surgical procedures other than sterility. Thousands of errors occur each year during surgical procedures. The Joint Commission is an independent nonprofit organization that accredits health care organizations. Its primary focus is to “promote patient safety and quality
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C R I T I C A L T H I N K I NG CHALLENGE You are assisting with a procedure when you notice that the other medical assistant’s back brushes up against the sterile field. 1. Is this a breach of sterility? 2. Should you alert the physician? If so, what would be the appropriate way to handle such a situation?
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F IEL D S M A R T S Even though the risk of misidentifying the patient, site, or procedure is much smaller in ambulatory care, mix-ups may still occur. Never assume that because you work in a small practice that you are immune to these types of errors.
of care.” The commission modifies its National Patient Safety Goals annually. Patient safety goals should be explored and reviewed annually to ensure compliance. National Patient Safety Goals that apply to the ambulatory surgery environment include: 1. Labeling all medications, medication containers (syringes, medicine cups, or basins), or other solutions on and off the sterile field 2. Reducing the risks of surgical fires through staff education and equipment maintenance procedures
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3. Using protocol for preventing “Wrong Site,” “Wrong Person,” and “Wrong Procedure” errors. This standard includes the use of two identifiers when identifying the patient, having the patient mark the site where the surgery is to be conducted, and verifying what procedure is to be performed with the patient immediately prior to the procedure.
PREPARING FOR OFFICE SURGERIES There are many responsibilities in preparing for patient surgeries. The preparation phase begins days before the surgery to make certain that all necessary supplies and equipment are available and in good working order, and to ascertain that patients understand their responsibilities in preparing for the procedure. Patient instructions are usually reviewed during the surgical consultation, but may be reemphasized a few days before the surgery over the phone or through e-mail. Table 24-1 lists common tasks that should be performed days prior to the procedure.
TABLE 24-1 Tasks to Be Completed Days Prior to the Procedure PROVIDE THE PATIENT WITH THE FOLLOWING INSTRUCTIONS
SURGERY ROOM RESPONSIBILITIES
INSURANCE RESPONSIBILITIES
Any fasting or medication instructions
Block off the surgical suite in the appointment scheduler to prevent double booking.
Notify the insurance company of the anticipated procedure.
Any special preparation instructions (skin cleansing, bowel cleansing, etc.)
Check all equipment to make certain it is in top working order. Check to see if new bulbs or batteries are needed for endoscopes, electrocautery units, etc.
If necessary, send in precertification paperwork.
What clothing and shoes to wear and what not to wear (expensive jewelry, constricting clothing, etc.)
Make certain that all supplies that are necessary for the procedure are in stock and that all instruments or instrument packs are available and in good working order.
Obtain approval from the insurance company well before the procedure is scheduled.
What paperwork, x-rays, or insurance information to bring the day of the surgery Who the patient should bring (The patient may not be able to drive following the procedure, may be a minor that needs an adult present, etc.)
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PA TIEN T P E R SP E C T I V E
C R I T I C A L T H I N K I NG CHALLENGE
I know that having a mole removal is no big deal to you, but it is to me. Several family members including my mom all have had skin cancer. My mom was diagnosed with melanoma and is doing pretty well now, but her whole life was turned upside down as a result of her cancer. I hate to admit it, but I am really afraid of needles too. I wish I could share my fears with the physician or you, but I am afraid that you will just think that I am overreacting.
Refer to the Patient Perspective tool box on this page to answer the following questions: 1. What information in the patient’s history would have alerted you that this patient may be extraordinarily anxious about having the procedure? 2. What signs may be displayed by a patient that is anxious? 3. What steps should you take if you sense that a patient is anxious about a procedure or the pending results of a procedure?
There are several tasks that will need to be performed the day of the surgery as well. Table 24-2 lists tasks to be completed the day of the surgery.
Setup Procedures Chapter 23 listed items that should be included on the surgical tray and side table for particular procedures,
but physicians often have their own special preferences for each procedure. Medical assistants may want to start a surgical card file that lists physician preferences for
TABLE 24-2 Tasks to Be Completed the Day of the Surgery PREPARING THE SURGICAL SUITE
ONCE THE PATIENT ARRIVES
Make certain that the room has been totally cleaned and disinfected prior to the procedure.
Greet the patient and escort the patient to an examination room.
Gather all necessary supplies including sterile packs, drapes, anesthetic, syringes, suture materials, solutions, bandaging materials, x-rays, and the patient’s chart.
If the surgical consent form (Figure 24-1) has not yet been signed, alert the physician. The physician is responsible for explaining the necessity for the procedure, what the procedure entails, risks associated with the procedure, and alternatives in place of the procedure. This whole process is known as informed consent.
Put any necessary x-rays on the view box.
Go over postop instructions with patient, including wound care instructions, medication instructions, and when to call the office (the patient is more alert before the procedure than following the procedure).
Place all necessary equipment in the room. Make certain that all equipment that will be used before the procedure is completely disinfected (electrocautery units, lasers, IV poles, crash trays, etc.).
Have the patient empty the bladder and change into an appropriate gown or other clothing.
Check all equipment to ascertain that it is in good working order. (Equipment defects may have developed since the initial inspection.)
Explain what the patient can expect throughout the remainder of the visit.
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CONSENT TO OPERATE Date
A.M. P.M.
Time
1. I authorize the performance upon of the following operation to be performed under the direction of Dr. 2. The following have been explained to me by Dr. A. The nature of the operation
B. The purpose of the operation C. The possible alternative methods of treatment D. The possible consequences of the operation E. The risks involved F. The possibility of complications
3. I have been advised of the serious nature of the operation and have been advised that if I desire a further and more detailed explanation of any of the foregoing or further information about the possible risks or complications of the above listed operation it will be given to me. 4. I do not request a further and more detailed listing and explanation of any of the items listed in paragraph 2. Signed (Patient or person authorized to consent for patient)
FIGURE 24-1 A sample of a surgical consent form
Witness
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F IEL D S M A R T S When using equipment that cannot be sterilized, such as electrocautery units or lasers, the equipment should first be disinfected. Then, sterile barriers should be placed over the equipment before moving it into the area where the surgery is being performed. The equipment should be placed a minimum of 12 to 24 inches away from anything that is sterile. This applies to any surgical procedure in which there is an open wound or incision.
procedures regularly performed (Figure 24-2). Each card should include the following: 1. 2. 3. 4. 5. 6. 7.
Items that should be included on the tray Items that should be placed on the side table Skin prep instructions Anesthetic preferences Equipment that should be placed in the room Glove and gown size of the physician Any other specific instructions
Before the patient enters the surgical suite, the medical assistant should set up the side table and gather supplies for the surgical tray and skin cleansing. Items should be placed in a logical sequence, usually in the order that each item will be used. Pull in any other necessary equipment such as an electrocautery unit or
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Surgical Items to be Placed on the Tray
Items to be Placed on the Side Tables
Skin Prep Instructions
Anesthetic
Extra Equipment in the Room
Dr.’s Glove Size and Gown Size
1 or 2% lidocaine or xylocaine without epinephrine
None
Dr. Turner: Glove size: 6 Gown size: Small
Syringe and needle
Appropriate anesthetic
1. Perform a surgical scrub over the site using concentric circles (one application).
Scalpel blade and handle
Packing gauze— Iodoform or plain
2. Wet shave only if absolutely necessary.
Dr. Wong: Glove size: 9 Gown size: Medium
Tissue forceps
Gauze/tape
3. Finish surgical scrub using a new sponge for each application for three solid minutes.
Dr. Winslett: Glove size: 11 Gown size: Large
Fenestrated drape
Biohazard/sharps containers
4. Rinse the area with sterile water.
Antiseptic solution (iodine-based)
Penrose drain (up to the physician)
5. Dry with a sterile towel.
Dissecting scissors/hemostat
6. Apply iodine antiseptic with sterile applicators (three applications).
Culture medium
Sterile gloves
Sterile gauze
PAT I E N T T U T O R The two most common prescriptions given to patients following a surgical procedure are antibiotics to fight infection and analgesics to assist with pain. Patients should be instructed of the importance of taking all of the antibiotics to prevent postop infections and should be encouraged to take the analgesic as prescribed on the label for the first few days following the
procedure. This will help prevent the patient from getting into pain trouble. Following the first couple of days, the patient should gradually taper down on the pain medication until the patient no longer has to rely on the medication. This will help to prevent the patient from becoming dependent on the medication.
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FIGURE 24-2 A surgical card file will help the medical assistant track each physician’s specifications.
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special laser units. Make certain that the sharps container and both the biohazardous and regular trash receptacles are strategically placed for easy disposal.
Once the Patient Enters the Surgical Suite Once the patient has signed the consent form, received home care instructions, disrobed for the procedure, and emptied the bladder, it is time to take the patient back to the surgical suite. The patient should be seated and appropriately positioned for the surgery. Select a position that will accommodate access to the site while providing comfort for the patient. The patient’s vitals should be taken and recorded in the chart and the site should be exposed for easy access. The surgical light should be angled so that it is directly over the surgical site.
(a)
Skin-Prep Procedures The skin harbors many microorganisms, and can be the trigger that sets the patient up for infection. Skin cannot be sterilized, but it should be cleansed in a manner that greatly reduces the number of microbes present. Skin-prep procedures will vary from office to office; however, the following steps are customary for preparing the skin for surgery: 1. Skin should be cleansed with an antimicrobial soap. 2. Skin should be shaved only if absolutely necessary and re-cleansed. 3. Skin antiseptic should be applied to the area (usually an iodine product). 4. The skin antiseptic should be allowed to completely dry before application of the fenestrated drape. 5. Apply the fenestrated drape (a drape with an opening that goes over the surgical site). Waterproof drapes should be placed under the patient before the cleansing begins. Disposable skin kits (Figure 24-3) include the supplies necessary to perform a skin-prep procedure. Both the surgical soap and antiseptic should be applied using concentric circles (circles that start in the center and work their way out to the periphery) as shown in Figure 24-4a. When shaving is absolutely necessary, the skin should be held taut and the razor should be angled in the direction that the hair grows (Figure 24-4b). Avoid nicks, as this could expose the patient to infection. Many hospitals and ambulatory surgery centers are now using clippers in place of razors to avoid nicks. Once the skin has been properly cleansed, rinsed, and dried, the antiseptic is applied using sterile sponge forceps or applicator sticks in a series of three applications. Sterile barriers
(b)
FIGURE 24-3 (a) An unopened disposable skin prep kit; (b) An opened skin prep kit
are placed under the site and the patient is instructed to keep the hands under the drape. New one-step sponge applicator kits are now available that contain chlorhexidine with alcohol or iodophor with alcohol. When such kits are used, the patient
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FI E L D S M A R T S When using electrosurgical equipment such as lasers or electrocautery units, make certain that the surgical site is completely dry and free of fumes. When using one-step skin-prep kits, ensure all drapes with antiseptic solution have been removed and replaced with new drapes. The alcohol in the skin-prep solution can cause a fire from a spark.
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ing the solution into the sponge. The medical assistant will apply the one-step solution by painting concentric circles over the surgical site for the prescribed amount of applications (usually three). The area dries very quickly because of the alcohol in the mixture. Refer to Procedure 24-2 for complete instructions on performing skin prep using the one-step procedure.
Preparing the Mayo Stand and Setting Up the Surgical Tray
Start in center
End
FIGURE 24-4a When applying surgical soaps or skin antiseptics, apply using concentric circles.
30°
The surgical tray is the last item prepared to minimize its exposure to microorganisms. The tray should be positioned so that the top of the tray is even with the waist of the preparer. The tray should be cleaned with a disinfectant (usually alcohol) starting from the center and working toward the periphery. If a sterile barrier is going to be placed on the tray, the medical assistant will remove the drape from the peel-apart package and carefully place it on the tray without contaminating it. The drape’s outer 1 inch border is usually marked with a dotted line and identifies the margin of safety between the part of the drape that is considered sterile and the part that is not. The portion of the drape outside the dotted line is the only part of the drape that should be handled when removing it from the pack and placing it on the tray. Special care should be taken to make certain that the drape does not drag over the tray, side table, or come into contact with the medical assistant during removal from the package and placement on the tray. The side of the drape that is facing the medical assistant is the side that will be placed downward on the tray. Refer to Procedure 24-3 for instructions on disinfecting a tray and preparing a sterile barrier.
Placing the Instruments and Other Items on the Tray
FIGURE 24-4b Statistics show it is best not to shave unless absolutely necessary. If it is necessary, use a 30° angle and shave in the direction that the hair grows.
receives a special antiseptic soap to use when washing on the morning of the surgery. The medical assistant will observe the skin to make certain it is clean and free of gross contamination. The one-step sponge applicator handle will have a special mechanism for releas-
Once the Mayo stand has been properly prepared, the instruments and other items are placed onto the tray. Items may be opened singly or collectively, as when using a prepared tray of instruments. When placing items singly onto the field, a sterile drape is initially placed on the field as mentioned above. When opening a prepared tray of instruments, the tray’s inner wrap is used as a sterile drape. All packs should be thoroughly examined to ascertain the integrity of the wrapping material. The medical assistant should make certain that no moisture, tiny holes, or tears exist anywhere in the wrapping material and that the tape or indicator strip on the wrap has turned the appropriate color. Check to make certain that the pack has not
ASSISTING WITH MINOR OFFICE SURGERIES AND WOUND CARE PROCEDURES
yet reached its expiration date. Any packs that do not fall into the above parameters should be discarded and replaced with a new pack. Once the pack is opened, the sterile indicator strips on the inside of the pack should be checked to make certain that the pack has met the parameters necessary for complete sterilization. Refer to Procedure 24-4 for complete instructions on opening wrapped packs and peel-apart packs and placing them onto the sterile field. Pouring the Sterile Solution Sterile solutions generally should not be poured until just before the procedure begins. Two labeled containers are usually placed on the field at the time the tray is prepared. Common solutions used in minor office surgeries are sterile saline and iodine. The names of the solutions, their strengths, and their expiration dates should be checked a minimum of three times prior to use. Once the solution is opened, only the top rim of the bottle should be advanced over the bowl (Figure 24-5). The solution should be poured from a distance of 2 to 6 inches above the field and poured slowly to avoid splash. Either all of the solution should be used, or the remainder that is not used should only be used for nonsterile procedures; once the solution has been opened, it is no longer considered sterile. Refer to Procedure 24-5 for further information on setting up a complete sterile tray and pouring a sterile solution.
FIGURE 24-5 When pouring a sterile solution into a sterile container, just advance the top rim of the solution over the container to avoid contaminating the field.
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FI E L D S M A R T S Some offices cover the tray with a sterile barrier once the tray is arranged to keep dust particles and other microorganisms from contaminating the tray. However, recent research indicates that there may be greater risks for contamination when applying and removing drapes. Air currents from the application and removal of the drape may actually pull more microorganisms toward the tray then when the tray is left standing completely still. Shifting of drapes during barrier application and removal may also pose a contamination threat. To reduce the risk of contamination, you should avoid setting up the tray until just prior to the beginning of the procedure.
PERFORMING A SURGICAL HANDWASH AND APPLYING SURGICAL ATTIRE The medical assistant will only need to perform a surgical handwash and apply surgical attire if working with the physician over the sterile field. In many minor office surgeries, the physician is the only one that will “scrub in” and apply surgical attire. The medical assistant’s duty during these types of procedures is to perform the duties of a circulator. The circulator is the person who circulates throughout the room to give additional items to the physician or to collect items as necessary. The circulator is considered nonsterile and must be careful not to contaminate other surgery personnel or the field. If the medical assistant is going to scrub in, the medical assistant should begin by performing a medical aseptic handwash and applying the surgical cap, goggles, and mask. The purpose of applying these items ahead of time is to prevent contaminating the freshly washed hands following the scrub. The goggles, mask, and cap are not considered sterile, which is why they are applied prior to the surgical scrub. The cap helps to prevent hairs from falling onto the sterile field and the mask prevents air droplets from contaminating the patient or tray. Goggles help to protect the medical assistant’s eyes from possible splash.
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Surgical sinks, like the one shown in Figure 24-6, are usually very deep to avoid splashing. They are operated with a foot or knee control or an electric sensor so the medical assistant will not have to use the hands to turn the water on and off. Scrub brushes are used to cleanse the hands and may be packaged with a surgical soap dispenser that is attached to the brush. Common surgical soaps include Hibiclens and iodine products. The surgical handwash is much more thorough and harsh than a medical aseptic handwash and is designed to eliminate large numbers of microorganisms on the skin by removing dirt, oils, and dead skin cells. Once the scrub is concluded, the hands should be dried with a sterile towel. Once the hands are properly cleansed, the gown and gloves are applied. The medical assistant must avoid touching any part of the gown that is considered sterile. Parts of the gown that are considered sterile include:
Nonsterile
Sterile Area
Nonsterile
❖ The front of the gown from the axillary line down to the waist ❖ The sleeved area of the gown, from the gloved fingers to 3 inches above the elbow Figure 24-7 illustrates which parts of the gown are considered sterile and which parts are not. Refer to Procedure 24-6 for complete instructions on applying surgical attire.
FIGURE 24-7 This sketch depicts which parts of the surgical attire are considered sterile and which parts are not.
ASSISTING THE PHYSICIAN BEFORE AND DURING THE PROCEDURE FIGURE 24-6 The depth of a surgical sink helps to prevent splashing and also decreases risks of accidentally contaminating the hands.
Assisting the physician with related tasks before and during the procedure includes tasks that will vary with each physician. The medical assistant should query physicians before working with them to determine specific preferences.
Pre-Procedure Tasks The medical assistant will usually have the responsibility of laying out the physician’s gloves, gown, mask, and goggles prior to the procedure and may need to assist the physician with gowning by snapping the gown closed once it has been applied. Once the physician is situated, the physician will anesthetize the patient. The medical assistant should be prepared to hand the appropriate items to the physician, including the syringe and needle (if not on tray), and be prepared to hold the anesthetic vial for the physician during withdrawal of the medication (Figure 24-8). The assistant should always clean the top of the vial with alcohol and call out the name and strength of
ASSISTING WITH MINOR OFFICE SURGERIES AND WOUND CARE PROCEDURES
the anesthetic, as well as any additives included in the anesthetic before presenting it to the physician. When presenting the physician with items from peel-apart packages, the medical assistant should peel the packing downward until enough of the item is exposed for the physician to grasp. The packet should be slightly rotated so that it is facing the physician and advanced for easy retrieval (Figure 24-9).
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At the Conclusion of the Surgery
1. Handing the physician items that are not on the sterile tray but are on the side table, such as suture material and extra sponges 2. Replacing instruments that may become contaminated during the procedure 3. Using the foot control to open the lid on various trash receptacles and holding the sharps container when necessary (don a pair of clean gloves when handling sharps containers) 4. Receiving patient specimens from the physician (don a pair of clean gloves before accepting any specimens)
The medical assistant’s role at the conclusion of the surgery is to assist the physician with the removal of surgical attire, to clean the patient’s skin, and to apply a sterile dressing and bandage over the surgical wound. The wound is usually closed at this point but may still be vulnerable to infection, so sterile principles should be applied when dressing the site. Once the cleanup and bandaging phases are completed, the medical assistant should remove gloves, wash hands, and retake the patient’s vital signs. Once the physician reexamines the patient following surgery, the caregiver may be called back to assist the patient in getting dressed. Ask the patient and caregiver if they have any further questions and remind them of the next appointment date. Encourage the patient to call if any questions arise. Following the patient’s dismissal, the medical assistant should dispose of all trash, and gather instruments and place them in a basin to soak. All linens should be placed in their proper receptacles, and the room should be completely cleaned and disinfected. The physician is usually the one responsible for documenting the procedure; however, the medical assistant is usually responsible for recording vital sign measurements, skin-prep procedure, type of bandage applied, and home care instructions given to the patient.
FIGURE 24-8 The medical assistant may be responsible for hold-
FIGURE 24-9 This is the proper way to hand the physician
ing the anesthetic vial as the physician withdraws the medication.
contents from a peel-apart pack during a surgical procedure.
During the Procedure Once the procedure begins, the medical assistant should wash hands and check in with the patient on a frequent basis to make certain that the patient is comfortable. The medical assistant should be prepared to assist the physician with the following:
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WOUND CARE Wounds may be intentional (as in surgical wounds) or the result of an accident. They are classified as either closed wounds (wounds that do not break the skin) or open wounds (wounds that do break the skin.) They may be acute (sudden onset, short duration, usually less than 30 days) or chronic (long duration, usually longer than 30 days). Chapter 35 lists different types of wounds and provides first aid instructions on how to treat accidental wounds. The remainder of this chapter will deal specifically with the healing process of an open wound and will list instructions for properly dressing open wounds.
Stages of Wound Healing The healthy body has internal mechanisms that help to protect skin that has been compromised. Wound healing involves a complex array of events and includes three major stages:
Blood clot Lymphocytes and macrophages
Epidermis
Dermis Erythrocytes Platlets
Blood vessel Hemostasis
Inflammation
FIGURE 24-10a Inflammatory stage: The two phases of the inflammatory stage are hemostasis and inflammation. During hemostasis, blood vessels constrict and platelets rush to the site to assist with clot formation. During inflammation, blood vessels dilate and white blood cells gather to assist in the removal of bacteria and debris. Contraction
1. First stage (inflammatory stage) (Figure 24-10a): This stage lasts for two to five days following the initiation of the wound. It consists of two different phases: hemostasis and inflammation. During hemostasis, blood vessels constrict to help control bleeding. Platelets (cells active in blood clotting) and thromboplastin assist in the formation of a blood clot. During the inflammation phase, blood vessels dilate and white blood cells rush to the site to assist in the removal of bacteria and debris from the wound. The entire process stimulates erythema, edema, and warmth to the affected tissue. 2. Second stage (proliferative stage) (Figure 24-10b): This stage follows the first stage, usually lasts anywhere from a couple of days to three weeks, and contains three phases: granulation, contraction, and epithelialization. During the granulation phase, fibroblasts stimulate the release of collagen, which helps to fill in the open wound. Growth cells stimulate the growth of new cells and blood vessels. Angiogenesis, or the formation of new blood vessels, occurs during this phase. During the contraction phase, the edges of the wound contract, which helps pull the wound together. During the epithelialization phase, epithelial tissue starts to form over the wound area, preparing it for closure. 3. Third stage (maturation and remodeling stage) (Figure 24-10c): This stage may last for a couple of weeks up to two years depending upon the severity of the injury. During this stage new collagen forms, resulting in a buildup of scar tissue. The buildup of scar tissue changes the shape of the wound and gives the tissue more strength. Scar tissue is not as
Epithelial cells bridge wound Angiogenesis Collagen fibres
Growth cells
Fibroblast
FIGURE 24-10b Proliferative stage: Fibroblasts stimulate the release of collagen, which helps to fill in the open wound. Angiogenesis (the formation of new blood vessels) occurs, the edges of the wound start to pull together, and epithelial tissue starts to form over the wound.
Epithelial bridge New collagen scar tissue
FIGURE 24-10c Maturation and remodeling stage: New collagen forms, resulting in a buildup of scar tissue. The buildup of scar tissue changes the shape of the wound and gives the tissue more strength.
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sturdy as healthy skin and may become damaged easier than skin that has not been compromised.
Today’s Wound Care Philosophy Wound care management has changed dramatically over the past several years and is a soaring industry. A recent report by Frost and Sullivan, a global growth consulting company, states that “the cost of treating chronic wounds [is] at $5 billion to $7 billion annually,” and that “these wounds are increasing at a rate of 10% per year” (Infection Control Resource, Volume 1, No 2). Physicians traditionally believed that it was best to scrub wounds with antiseptics because of their ability to inhibit the growth of microorganisms. The latest studies reveal that cleaning the wound with anything other than normal saline could actually inhibit the healing process. Antiseptics such as iodine products and peroxide are now believed to be toxic to leukocytes and fibroblasts, which are necessary cells for wound healing. (However, iodine products are still used to cleanse the skin prior to surgical procedures.) Traditional wound care management emphasized a clean, dry environment and encouraged the use of dressing materials that laid directly against the wound to help absorb exudate, or the fluid that is secreted by the tissue (including blood, pus, dead cells, and tissue fluid) as a result of disease or injury. However, the latest studies conclude that wound exudates contain growth factors that stimulate new cell and vessel formation, as well as other cells involved in immunity that help to protect the wound against infection. Unfortunately, these absorbent dressings not only absorb the exudate but also absorb the healing components within the exudate that are essential for proper healing. Current guidelines encourage wound care treatments that enhance the body’s natural healing process. Three main goals for the treatment of wounds include increased moisture (on the inside of the dressing), warmer temperatures, and control of bacteria. Warm, moist dressings help to speed up the healing process by stimulating the re-epithelialization rate, increasing collagen synthesis, and decreasing the amount of fluid lost from the wound. Bacteria growth is controlled by using aseptic techniques when changing dressings and designing dressings that keep external moisture from entering the inside of the wound. Dressing manufacturers have designed a variety of dressings to accommodate all of the goals of wound care management. Steps for good wound care include the following: 1. Cleaning and debridement: When the skin is severely damaged, debridement (removal of dead
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tissue) may be necessary. Dead skin can hamper the healing process. Debridement can be accomplished in a variety of different ways. It may be performed through irrigation, or the flooding of the wound with a sterile liquid such as sterile saline. It may be performed naturally through a process known as autolytic debridement. Autolytic debridement is achieved by applying a moist dressing to the wound and allowing it to become dry. The particles from the wound dry onto the dressing and the dressing is gently removed. In severe cases such as burns, debridement may be performed mechanically with the use of sterile scalpels or scissors. 2. Application of a sterile dressing: The application of a sterile dressing helps to keep dirt and bacteria out of the wound, and the special materials and additives within each dressing may help to speed up the healing process. The process for dressing selection is discussed later in the chapter. 3. Preventing further injury: It is important for the patient to protect the wound from further injury. The tissue is fragile, and any new injury will destroy the healing that has already occurred and possibly cause more complications. 4. Preventing infection: The patient should be encouraged to wash the hands before and after every dressing change and to never touch an open wound with bare fingers. Giving the patient a set of written instructions for wound care management will help the patient understand how to properly care for the wound and become more compliant.
Types of Dressings There are several different types of dressings available today that help to enhance the healing process (see Table 24-3). The type of dressing selected will be based on several factors, including the amount of drainage present, whether the wound is acute or chronic, what phase of healing the wound is in, and the physician’s preference. Dressings can be classified as either primary or secondary dressings. Primary dressings are dressings that lay directly over the wound. These dressings are usually nonadherent and are impregnated with some kind of ointment or water that keeps it from sticking to the wound and helps keep the internal environment moist. Secondary dressings are usually placed over primary dressings and assist with absorption of excess wound fluid or exudates from the inside, while keeping outside moisture and bacteria from entering the wound. Adherent dressings are designed to act as a skin substitute and are good for patients with partial thickness burns.
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TABLE 24-3 Types of Dressings TYPE AND EXAMPLES
PROPERTIES
WHEN TO USE
PROS
CONS
Gauze
Plain cotton material
Should only be used on minor wounds or as a secondary dressing
Absorbs drainage
Sticks to skin May disrupt the wound bed when removed May inhibit the healing process
Hydrocolloids
Main component is cellulose, which turns into a gel during exudate absorption and helps to keep the wound moist
Used on wounds with light to heavy drainage or on wounds that are granulating
Promotes autolytic debridement Adheres to moist skin
May promote hypergranulation Can cause the edges of the wound to become macerated
Hydrogels
Polymer gel composed of absorbent polymers with a gel structure that has a high water content
Used on wounds that are sloughing off or that have necrotic tissue Should not be used on wounds with moderate to heavy exudates Very useful on burns
Rehydrates tissue Minimally absorbent Cool and soothing to tissue
May be slippery and difficult to keep in place May cause maceration of skin around wound edges
Alginates
Composed of Good for clean calcium alginate exudating wounds Works by exchang- Aids in debridement ing calcium on the dressing with sodium from fluid coming from the wound Turns the dressing into a gel, promoting a moist environment
Highly absorbent May be slightly hemostatic
Can dry a wound with limited drainage Can dry out the dressing May leave fibers from the dressing in the wound
Collagens
Contains a hydrogel with collagen, which helps to stimulate the formation of collagen in the wound bed
Absorbs exudates Provides a moist environment
Attracts macrophages and fibroblasts Encourages autolytic debridement
The collagen gels are heat sensitive and may become altered with excessive heat Some people may be allergic to products in the gel
Foams
Made of a polyurethane foam pad
Good for wounds with large amounts of drainage
Very absorbent Breathable Less frequent bandage changes Reduces skin maceration
Could promote wound drying May not adhere well to deeper wounds
Transparent films
Clear film dressing
Used as a secondary dressing Great to secure IVs
Permits visibility of the wound Promotes autolytic debridement Contours to body parts Waterproof so patients can shower
May experience difficulty in applying and removing Zero absorbency May be irritating to tissue
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Many of the latest wound care dressings contain multiple layers to create optimal conditions for wound healing. Refer to Figure 24-11 for a picture of various types of dressings.
Applying and Caring for Dressings Guidelines for applying and caring for dressings include: 1. Wash your hands thoroughly before bandaging. 2. Use sterile technique and products when applying dressing to wounds that are open. 3. Use an ointment only if directed to do so by the physician (refer to the Field Smarts tool box on this page). 4. Encourage patients to change dressings that appear dirty. 5. Avoid ripping or tearing a bandage away from a wound. This could reinjure the site. Instead, soak the bandage with normal saline for several minutes. Always pull a dressing toward the wound when removing. 6. Document the following after removing a dressing: appearance of the dressing and bandage, and wound. Record any unusual drainage and the color of the drainage, and report any unusual odors coming from the area. Terms used for exudates include the following: a. Serous: Fluid that contains serum. Serous fluid may appear as a clear fluid but sometimes is also yellow. b. Sanguineous: A discharge that contains blood.
FIGURE 24-11 Examples of different dressings used in wound care
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FI E L D S M A R T S Antibacterial ointments are not used as readily in today’s wound care management due to sensitivity and allergic reactions from the ointments. In cases where ointment is ordered, you should start by making certain that the site is clean so that the ointment does not seal in the bacteria. Only a thin layer of ointment should be applied; thicker layers may produce more moisture, resulting in an increase in bacteria. The ointment should be applied with a sterile cotton-tip applicator.
c. Serosanguineous: A discharge that contains both serum and blood. d. Purulent: A discharge containing pus.
Types of Bandage Material A bandage and a dressing are uniquely different from one another. A dressing is applied over an open wound and a bandage is wrapping material placed over a dressing or closed skin. The selection of bandage material will be based on the goals for bandaging, which may include: 1. To hold a dressing in place 2. To immobilize a joint 3. To hold a dressing and to immobilize a joint Refer to Table 24-4 for a listing of different bandage materials.
Guidelines for Bandaging Bandaging tips include: 1. Always place a sterile dressing over an open wound before applying a bandage. 2. Use sterile asepsis when applying a dressing and medical asepsis when removing a dressing. 3. The area should be clean and dry prior to bandage application. 4. Always wrap distal to proximal. 5. Bandages should extend 1 to 2 inches beyond the dressing. 6. Pad bony surfaces and joints to prevent friction. 7. Bandage body parts in their normal positions, slightly flexed to avoid muscle strain or damage.
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TABLE 24-4 Different Types of Bandaging Material Kling roller gauze material (Figure 24-12a)
Used quite often to cover a dressing and hold it in place Does not conform well and may need additional bandaging material to properly cover wound
Elastic cloth bandage (Figure 24-12a)
An ace bandage or a wrinkled crepe-like bandage that conforms to body shapes and is great for immobilizing joints or covering uneven body surfaces
Tube gauze (Figure 24-12b)
Long, tube-shaped gauze that fits over a cage-like apparatus Used to cover long, slender parts of the body such as the fingers and toes
FIGURE 24-12a Roller gauze material and elastic cloth bandages
FIGURE 24-12b Tube gauze with holders
8. Leave fingers and toes open when applying a bandage to the extremities so that circulation may be evaluated. 9. Check for signs of poor circulation, which include blueness around the nail beds, pallor, skin temperature changes, tingling sensation, and numbness.
turn should be approximately half to three-fourths of an inch apart. ❖ A reverse spiral turn (Figure 24-13c) is used in order to fit more snugly around the varying contours and dimensions of a limb. Start with a spiral turn and reverse halfway through each turn. ❖ A figure-eight bandage (Figure 24-13d) is used to immobilize a joint or to hold a dressing in place. Start with two circular turns around the hand to anchor the bandage. Roll the gauze diagonally across the front of the joint in a figure-eight pattern, crossing above the joint and then below the joint. Continue until the joint is completely immobilized.
Refer to Procedure 24-7 for complete instructions on wound care, including removing an old dressing, irrigating, and applying a new dressing.
Methods of Bandaging The method of bandaging used is based on the goals for bandaging listed above. Different methods include: ❖ A circular turn (Figure 24-13a) is used to anchor a bandage at the beginning or end of a spiral, reverse spiral, figure-eight, or recurrent turn. ❖ A spiral turn (Figure 24-13b) is used when wrapping body parts that are uniform in size. The wrapping material should be wrapped in a spiral fashion by overlapping the previous turn. Each
Wound Care Alternatives Chronic wounds are often difficult to treat. Wounds that do not heal properly may be the result of circulatory problems, diabetes, immune suppression, vasculitis, ischemia, and malignancies. When chronic wounds
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(a)
(b)
(c)
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(d)
FIGURE 24-13 Examples of different bandaging techniques: (a) a circular turn, (b) a spiral turn, (c) a reverse spiral turn, (d) a figure-eight turn.
do not heal, physicians often look for alternative treatments. Two alternative treatments are subatomospheric pressure dressings and hyperbaric oxygen therapy. A subatmospheric pressure device (Figure 24-14) uses negative pressure to help close wounds. The physician will start by thoroughly debriding the wound to remove loose or necrotic tissue. Next, the physician will place a piece of sterile foam into the wound, which is sealed with a special adhesive dressing. A hole is cut just slightly above the foam for placement of the tube. Once the pump is turned on, the vacuum will aspirate fluid from the wound, sending it to a receiving canister attached to the unit. The vacuum causes the foam to compress and pull the wound edges together, which
helps to promote closure of the wound. The negative pressure increases circulation, promotes a moist environment, and reduces the bacterial load. Hyperbaric oxygen (HBO2) therapy (Figure 24-15) involves placing the patient into a hyperbaric chamber to treat difficult wounds. The patient undergoes a series of three phases while in the chamber. The first phase, called compression, occurs as oxygen flows into the unit. The second phase, treatment, begins once the chamber has reached the desired oxygen level and continues for the amount of time prescribed. Decompression, the third phase, signifies the termination of the treatment and occurs when oxygen levels are returned to their normal levels.
FIGURE 24-14 The V.A.C. is an example of a negative pressure
FIGURE 24-15 A hyperbaric oxygen (HBO2) chamber (Courtesy of Oxyheal Health Group.)
wound therapy device. (Courtesy of KCL Licensing, Inc.)
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PROCEDURE 24-1 Perform a Surgical Handwash and Apply Surgical Gloves Objective: To perform a surgical handwash and apply sterile gloves in an appropriate manner.
Equipment/Supplies: ❖ Sterile brush impregnated with antiseptic soap/fingernail cleaner ❖ Sink/basin
❖ Sterile towel ❖ Package of sterile gloves
PROCEDURAL STEPS
RATIONALE
1. Peel apart a sterile towel without contaminating it and lay the towel on a flat, clean surface close to the area where the handwash is to take place.
Opening the towel ahead of time prevents you from contaminating your hands once they have been scrubbed.
2. Place gloves beside the sterile towel and remove them from the outer wrapper (Figure 24-16). Unfold the pack so that it lies flat. Carefully open each flap of the inner wrapper to expose the gloves without contaminating them. The gloves should be positioned so that the cuffs are facing you, and the thumbs are pointing outward.
Same as above.
3. Open the sterile scrub pack containing the impregnated scrub brush and nail cleaner. Do not remove them yet. Place them in the sink area. 4. Remove all rings and watches and place them in your pockets. Turn on the water using the automatic sensor or foot or knee control and adjust the temperature (should be warm, not hot).
Using a sink with automatic sensors or a foot or knee control will keep you from touching the already dirty sink. Hot water can be damaging to the skin.
5. Rinse your hands under the water, keeping the hands and fingers pointed upward and the arms well above the waist (Figure 24-17).
Hands and fingers should be pointed upward and above the waist throughout the entire procedure to prevent dirt from the upper part of the hands and arms from running back down over scrubbed areas.
6. Using just the nail stick and water, clean under each nail (Figure 24-18). Drop the nail stick in the sink and rinse hands.
The undersurfaces of nail beds contain many microorganisms that must be removed before cleansing the hands.
7. Completely wet your hands, wrists, and forearms up to the elbow, keeping hands and fingers pointed in an upward position and well above the waist.
Wetting these areas will assist in the scrubbing process.
8. Obtain the impregnated brush and start the scrub on the palm of the hand (Figure 24-19) and move to the base of the thumb using a circular pattern. Do not go over a section that has already been scrubbed, or you will contaminate it.
Going over a section that has already been scrubbed will contaminate the section.
ASSISTING WITH MINOR OFFICE SURGERIES AND WOUND CARE PROCEDURES
FIGURE 24-16 The sterile
towel and gloves should be laid FIGURE 24-17 out just prior to the scrub itself. When rinsing fingers, hands, and arms, be careful to keep the arms above the waist, and keep fingers pointed in an upward position.
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FIGURE 24-18
FIGURE 24-19
FIGURE 24-20
Nails harbor many microorganisms and must be cleaned in addition to the skin.
Start the scrub on the palm of the hand and work to the base of the thumb using a circular pattern.
Dry hands using a patting motion with a sterile towel starting at the fingertips and working downward. Switch to the opposite side of towel when drying the opposite side.
PROCEDURAL STEPS 9. Next, move to the fingers. Scrub each surface of each finger using several vertical strokes from the base of each finger to the nail (there are a total of four surfaces for each finger). Be certain to scrub the skin between the thumb and index finger as well.
RATIONALE Each surface of each finger must be cleansed in order to achieve complete cleansing.
10. Once the fingers are completely scrubbed, turn the hand over and scrub the posterior portion of the hand extending to below the wrists using a circular pattern. 11. Next, scrub the forearm using a circular pattern from the wrists to slightly above the elbow. Make certain to scrub all four surfaces.
All surfaces from the fingertips to the elbows must be scrubbed to achieve proper cleansing.
12. Rinse both the arm that was just scrubbed and the opposite arm with arms well above the waist and fingers pointed upward. Water should run from the finger tips down the arms and over the elbow. Do not touch any part of the sink while washing or rinsing.
Rinsing both arms allows the soap to be removed from the first arm and re-wets the opposite arm for better lathering. Touching any part of the sink will contaminate the hands or arms.
13. Wash the opposite side using the same steps as the first side. Drop the scrub brush in the sink and rinse thoroughly. The entire length of the scrub will vary between two and six minutes.
Dropping the brush in the sink keeps you from contaminating freshly washed hands. Scrub times will vary because each surgical antiseptic has its own scrubbing directions.
14. Turn off the water using the foot, knee, or sensor control when applicable.
This will prevent contaminating your hands.
15. Pick up the towel in your dominant hand by holding onto the corners. The towel should be several inches away from your body. Using just one side of the towel, start at the fingertips (Figure 24-20) on your nondominant hand and pat dry all the way up to the elbow, making sure that you dry all four surfaces simultaneously. Remember to keep the arms and hands above the waist with fingers pointed upward.
Rubbing the towel back and forth can bring contaminants from the dirtier surfaces (forearms) toward the cleaner surfaces (fingertips).
continues
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continued
RATIONALE
PROCEDURAL STEPS 16. Repeat the same procedure on your dominant hand using the opposite side of the sterile towel. 17. Once the hands are completely dried, walk to the clean, dry surface where the gloves are laying.
The gloves should be nearby but not directly on the sink so that they are not contaminated by splashing water.
18. Pick up the first glove by the inside cuff using your nondominant hand (Figure 24-21). Lift the glove up and away from the flat surface to avoid dangling the glove across a nonsterile surface. Slide the glove in an upward motion, over the hand (Figure 24-22).
If you do not completely lift the glove upward and away from the counter surface, you may accidentally drag or dangle the fingers over the counter and contaminate the glove.
19. Pick up the second glove with your dominant hand by slipping the four fingers from the gloved hand underneath the cuff of the second glove (Figure 24-23). Make certain that the thumb is facing outward. Slide the glove onto the hand without contaminating either glove.
Remember that sterile items can only touch sterile items. If you touch any part of the sterile glove to your wrist or hand, the glove is contaminated, and you will have to start all over.
20. Leaving your fingers under the cuff, unfold the cuff so that it slides down over the wrist (Figure 24-24). Do not allow the gloved thumb from the opposite hand to touch the inside of the cuff. Repeat the same procedure for the first glove (Figure 24-25).
Allowing the gloved thumb to touch the skin of the opposite hand will contaminate the glove.
21. Examine both gloves for any tears or problems.
The gloves may have become damaged during the application process.
FIGURE 24-21
FIGURE 24-22
FIGURE 24-23
FIGURE 24-24
FIGURE 24-25
Pick up the first glove using your thumb, index finger, and middle finger by grasping the edge of the inside cuff with your nondominant hand.
Slide the glove onto your dominant hand by pulling the cuff in an upward motion.
Pick up the second glove with your dominant hand by slipping the four fingers from the gloved hand underneath the cuff of the second glove.
Lift up your hand to avoid dangling and with fingers still positioned on the inside of the cuff, roll back the cuff on the nondominant hand over the wrist. Do not allow the gloved thumb from the opposite hand to touch the inside of the cuff.
Repeat the same procedure for rolling back the cuff for the glove on the dominant hand.
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PROCEDURE 24-2 Prepare the Patient’s Skin for the Surgical Procedure Using a One-Step Scrub Objective: To properly prepare the patient’s skin for a surgical procedure using a one-step method (when the patient cleanses the skin with a special soap the morning of the procedure).
Equipment/Supplies: ❖ Skin prep kit ❖ Absorbent pads
❖ Sterile drape ❖ Fenestrated drape
PROCEDURAL STEPS
RATIONALE
1. Wash your hands and gather the supplies. 2. Identify the patient using two identifiers. Verify that the patient followed the site cleansing instructions.
Complies with the Joint Commission National Patient Safety Goals and ascertains that you have the correct patient.
3. Identify yourself and explain the procedure.
Explaining the procedure will help the patient to know what to expect.
4. Expose the surgical site and drape the patient for modesty if necessary. Some facilities ask the patient to mark the area where the surgery is to take place with an X before prepping the skin.
Complies with the Joint Commission National Patient Safety Goals.
5. Position the patient for comfort and place absorbent drapes under the area to be cleansed (Figure 24-26).
The pads will keep the surface under the patient from getting wet.
6. Adjust the light so that it illuminates the surgical site. Inspect the skin for any gross contamination. If any gross contamination is visible, the skin will have to be thoroughly cleansed before applying the antiseptic cleanser.
If the area has not been properly prepped by the patient, the one-step procedure will not be effective in removing the microorganisms from the skin.
7. Open the skin-prep kit without contaminating the swab or the sponge applicator. 8. Wash your hands and apply sterile gloves.
FIGURE 24-26 Position the patient for comfort and place absorbent drapes under the area to be cleansed.
Even though the applicator will separate your hands from the sterile tip, you may need to use your other hand for stabilizing as you prep the skin.
9. Remove the swab or sponge, touching only the applicator or handle. 10. Apply the antiseptic scrub by painting concentric circles over the site (Figure 24-27).
The purpose of the circles is to move the microorganisms from an area of lesser concentration to an area of greater concentration (clean to dirty).
FIGURE 24-27 Apply the antiseptic scrub using concentric circles.
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PROCEDURAL STEPS
RATIONALE
11. Scrub normally lasts anywhere from 30 seconds to two minutes, which equates to about three separate applications with three separate applicators. Follow the physician’s orders. 12. If the physician orders the area to be shaved, pull skin taut and shave in the direction that the hair grows. Remember that shaving is not recommended unless absolutely necessary!
Nicks in the skin can set the patient up for infection.
13. Re-cleanse the skin according to office policy. 14. Remove absorbent pads and discard.
The wet pads are uncomfortable and can contaminate the dry sterile drapes that will be applied later.
15. Place a sterile pad under the surgical site.
The pad will act as a sterile barrier during the procedure.
16. Apply fenestrated drapes and other surgical drapes according to the physician’s preference (Figure 24-28).
Many physicians prefer to apply the fenestrated drape.
17. Instruct the patient to keep hands below the drapes (when applicable).
Touching the drapes will contaminate them.
FIGURE 24-28 Apply surgical drapes and fenestrated drapes according to the physician’s preference.
PROCEDURE 24-3 Disinfect a Surgical Tray and Place a Sterile Barrier on the Tray Objective: To clean the surgical tray and apply a sterile barrier using strict aseptic technique.
Equipment and Supplies: ❖ Mayo stand ❖ 4x4s saturated with disinfectant, but not dripping
❖ Sterile drape
ASSISTING WITH MINOR OFFICE SURGERIES AND WOUND CARE PROCEDURES
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RATIONALE
PROCEDURAL STEPS 1. Wash your hands. 2. Adjust the Mayo stand so that it is right about waist level.
When working in a sterile setting, your hands should always be above your waist.
3. Pick up the 4x4s saturated with disinfectant (but not dripping) by only touching the top side of the 4x4s. Clean the tray using the bottom side of the 4x4s using a circular motion until the whole tray is completely covered (Figure 24-29).
Touching only the top side of the 4x4s will keep you from contaminating the side that will clean the tray.
4. Allow the tray to air dry. 5. Select an appropriate sterile barrier and place it on a clean, dry, flat surface. 6. Peel back the top flap of the pack, completely exposing the drape. Make certain that the pack is positioned so that the cut corners are facing you.
You want to open it so that it can be removed in a sterile manner.
7. Using your thumb and forefinger, gently pull up one of the top corner edges of the drape without touching any other part of the drape. Lift the drape well above the counter surface and away from you.
If you do not lift the drape well above the counter and out and away from you, you may accidentally contaminate the barrier by dragging the drape over the counter surface or brushing it up against your clothes.
8. Grab the opposing corner so that both corners are now being held along the top edge of the drape. Keep the drape well above your waist and several inches away from your body (Figure 24-30).
Holding the drape well above your waist and several inches away from your body will keep you from contaminating the drape.
9. Pull the drape over the Mayo stand so that the part of the drape that was facing you is lying against the surface of the tray and the part that was facing away from you is now facing upward on the tray (Figure 24-31).
FIGURE 24-29 Clean the tray using the bottom side of the 4x4s using a circular motion until the whole tray is completely covered.
FIGURE 24-30 Grab the drape so that both corners are now being held along the top edge of the drape. Keep the drape well above your waist and several inches away from your body.
FIGURE 24-31 Pull the drape over the Mayo stand so that the part of the drape that was facing you is lying against the surface of the tray.
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PROCEDURE 24-4 Open Sterile Items and Place Them on the Sterile Field Objective: To correctly open and apply items to the sterile field without contaminating the field.
Equipment and Supplies: ❖ Mayo stand set up with a sterile drape ❖ Wrapped pair of sterile transfer forceps ❖ Wrapped single instrument in autoclave paper
❖ Wrapped gauze in a peel-apart wrapper ❖ Wrapped tray of instruments
PROCEDURAL STEPS
RATIONALE
Opening a Sterile Pack and Transferring Items to the Sterile Field Using Sterile Transfer Forceps 1. Wash your hands. 2. Place a sterilized pack of transfer forceps on the side table.
The transfer forceps are necessary to move the instrument to the field without breaking sterility.
3. Place the unopened sterilized instrument on the side table, examine the autoclave tape, and make certain that the stripes turned the appropriate color. Check the expiration date and the quality of the wrapper to make certain that the wrap has not been compromised. 4. Remove the tape from the packet and place it on the side table. Position the pack so that the flap that was taped is facing you.
The tape should be kept in case there are any problems with the pack.
5. Using only your thumb and index finger, grasp the tip of the folded flap that was covered with tape and pull it away from you.
Using more than two fingers to open the flaps may cause you to stray to an area of the flap that is sterile.
6. Using only your right thumb and index finger, grasp the tip of the folded-back flap on the right side and pull it all the way to the right. 7. Using only your left thumb and index finger, grasp the tip of the folded-back flap on the left side and pull it all the way to the left. 8. Using only your dominant thumb and index finger, grasp the tip of the last folded-back flap and pull it toward you without touching anything on the inside of the wrap. The entire instrument should be exposed for easy retrieval later. Check the sterilization indicator in the pack to make certain it turned the appropriate color; if not, remove the pack and get a new one. 9. Move to the packet containing the sterile transfer forceps. Open the sterile transfer forceps the same way you opened the first pack.
Never reach across a sterile field or wrap. That is why you use the hand that is on the side that is being opened.
ASSISTING WITH MINOR OFFICE SURGERIES AND WOUND CARE PROCEDURES
PROCEDURAL STEPS 10. Once the pack is opened, grasp only the handles of the sterile transfer forceps by placing your thumb in one ring and your index finger in the other ring. Do not touch any other part of the instrument. Lift the transfer forceps straight up, keeping the tips facing downward but well above the height of the side table.
RATIONALE Touch only the handles of the instrument so that you do not break sterility. Keeping the tips facing downward will keep the instrument as free from wind currents as possible.
11. Move the transfer forceps to the instrument that needs to be transferred to the sterile field (Figure 24-32). Once you are positioned in front of the sterile instrument, lower the transfer forceps to the sterile instrument and securely grasp the instrument. Lift the instrument well above the height of the side table and approach the sterile tray. Standing a few inches away from the field, gently lower the sterile instrument onto the tray (Figure 24-33). Do not allow your hand to drop below the level of the handle. 12. Once the instrument has been fully transferred to its appropriate place on the tray, pull the sterile transfer forceps up and away from the field and set them back down on the side table.
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FIGURE 24-32 Move the transfer forceps to the instrument that needs to be transferred.
Once the instrument has been returned to the side table, it is considered contaminated.
Opening a Peel-Apart Pack FIGURE 24-33
1. Inspect the package and make certain that the integrity of the wrap has not been altered. Check the control strip to make certain that it turned the correct color. Check the expiration date to make certain that the pack is not expired.
Standing a few inches away from the field, gently lower the sterile instrument onto the tray. Do not allow your hand to drop below the level of the handle.
2. Position yourself so that you are in front of the tray but several inches away from the field. 3. Grasp both the top edges of the peel-apart pack and carefully peel them apart by rolling the wrap downward on both sides. 4. Once the wrap has been peeled to the point that the item can be transferred to the field, turn your hands inward and push the pack forward so that the item is just slightly over the field (Figure 24-34). The hands should be well above the field. Gently drop the item onto the field.
Turning your hands inward creates a barrier between your hands and the sterile field. Reaching over the center of the tray sets the tray up for contamination. FIGURE 24-34 Once the wrap has been peeled to the point that the item can be transferred to the field, turn your hands inward and push the pack forward so that the item is just slightly over the field.
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PROCEDURE 24-5 Set Up a Complete Sterile Tray and Pour a Sterile Solution Objective: To correctly set up a surgical tray and pour a sterile solution so that nothing becomes contaminated.
Equipment/Supplies: ❖ Liquid antibacterial soap and sink to perform an aseptic handwash ❖ One wrapped tray of instruments with liquid basins to pour the sterile solutions into ❖ Mayo stand ❖ Small bottle of sterile saline
❖ Small bottle of sterile betadine ❖ 4x4s saturated with disinfecting solution ❖ Package of sterile gloves or sterile transfer forceps ❖ Bottle of alcohol-based hand sanitizer (to cleanse hands before applying surgical gloves)
PROCEDURAL STEPS
RATIONALE
1. Perform an aseptic handwash using antibacterial soap and water.
Clean hands reduce the spread of microorganisms.
2. Gather the supplies and place them on the side table.
Once you start setting up the tray, you may never turn your back on the tray. You must ensure that the tray does not become contaminated.
3. Properly position the Mayo stand so that it is at your waist level.
Dropping your hands below your waist could cause you to accidentally touch yourself or another object, which could lead to contamination of the sterile tray, especially when wearing sterile gloves to set up the field.
4. Clean the Mayo stand with 4x4s that have been saturated with a disinfectant (but not dripping), cleaning in a circular motion.
This will minimize the number of microbes on the stand.
5. Allow the stand to air dry. 6. Check the instrument pack and make certain that the integrity of the pack has not been compromised.
You do not want to use instruments that are not sterile; doing so will increase the patient’s risk of a postop infection.
7. Check the tape on the outside of the pack to make certain that the stripes turned the correct color and that the pack has not reached its expiration date.
The stripes on the tape should turn a deep black color if the conditions were correct for sterilization to occur inside the autoclave.
8. Pull the tape off of the pack and place it on the side table.
If there is a problem with the pack, the physician will want to know who is responsible.
9. Place the sterile pack on the center of the Mayo stand so that the flap that was taped is facing you.
ASSISTING WITH MINOR OFFICE SURGERIES AND WOUND CARE PROCEDURES
❖
RATIONALE
PROCEDURAL STEPS 10. Using only your thumb and index finger, grasp the tip of the folded flap that was covered with tape and pull it away from you (Figure 24-35). 11. Using only your right thumb and index finger, grasp the tip of the folded-back flap on the right side and pull it all the way to the right (Figure 24-36).
Reaching over the field to pull back the flap can contaminate the field.
12. Using only your left thumb and index finger, grasp the tip of the folded-back flap on the left side and pull it all the way to the left (Figure 24-37).
Reaching over the field to pull back the flap can contaminate the field.
13. Using only your dominant thumb and index finger, grasp the tip of the last folded-back flap and pull it toward you without touching anything on the inside of the wrap (Figure 24-38). 14. Repeat steps 10 through 13 for the second layer of wrap. (The inner wrap will become your sterile drape.) 15. Move to the side table without turning your back on the field.
Never turn your back on the field; you could break sterility without being aware of it.
16. Open the pack of sterile gloves and remove them from the wrapper.
You will need sterile gloves on so that you can arrange items on the field without contaminating it.
17. Open the inner wrapper without contaminating the gloves. 18. Wash your hands with alcohol-based hand sanitizer following the directions on the bottle.
Using an alcohol-based scrub is very effective against reducing the number of microorganisms and saves time.
19. Apply surgical gloves—remember to hold your hands above the waist.
Dropping the hands below the waist will contaminate the gloves.
20. Approach the field facing forward and stand a few inches away from the field. Remove the items from the inside of the tray and place them on the sterile field in a logical sequence. Place the basins for the sterile solution on one corner of the stand facing upward.
You may contaminate the field if you are too close to the field. The basins should be on the corner so that you do not have to reach across the field when you set up the field.
FIGURE 24-35 Using only your thumb and index finger, grasp the tip of the folded flap that was covered with tape and pull it away from you.
FIGURE 24-36 Using only your right thumb and index finger, grasp the tip of the folded-back flap on the right side and pull it all the way to the right.
FIGURE 24-37 Using only your left thumb and index finger, grasp the tip of the folded-back flap on the left side and pull it all the way to the left.
FIGURE 24-38 Using only your dominant thumb and index finger, grasp the tip of the last folded-back flap and pull it toward you without touching anything on the inside of the wrap.
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PROCEDURAL STEPS
RATIONALE
21. Once the field has been totally arranged, remove the sterilization indicator from the inside of the tray and make certain that it is the proper color (Figure 24-39).
You want to make certain now that the conditions on the inside of the pack were ideal for sterilization to occur by checking the inside indicator. If not, a whole new pack will have to be set up.
22. Place the tray that held the instruments onto the side table. Do not turn your body away from the sterile tray as you place the instrument tray on the side table.
Turning your back to the field could cause you to accidentally contaminate the field without being aware of it.
23. Remove gloves and wash your hands with alcoholbased sanitizer.
The gloves will be unsterile once you touch the iodine, so there is no point in keeping them on anymore.
24. Pick up the brand new bottle of iodine and read the label. Make certain that you have the correct solution. Check the label to make certain that the solution has not passed its expiration date.
A new bottle of solution should be used whenever performing a surgical procedure to ensure the sterility of the solution.
25. Pick up the bottle of iodine, palming the label.
Palm the label so that if the solution drips as you pour it, it will not ruin the label. (You may use any remaining solution for nonsterile procedures.)
26. Remove the cap and place it to the side so that the lid is facing upward. Remove the protective seal and place it on the side table.
Never place a lid so that the inside of the lid is downward. This will contaminate the lid for future uses.
27. Move to the tray and approach the corner on which the basins are sitting.
Reaching across the field may contaminate the field.
28. Pour the iodine into the container labeled as iodine, pouring 2 to 6 inches above the field. Be careful not to allow the solution to splash. Fill to the desired level.
You do not want your hand to accidentally touch the bowl into which you are pouring the solution.
29. Repeat steps 24 through 28 with a new bottle of sterile saline, pouring into the container labeled as saline. 30. If the solutions are not used in their entirety, replace the caps and follow the institution’s policy for storing the solutions. Keep in mind that these solutions should not be used for any future surgical procedures.
FIGURE 24-39 Once the field has been totally arranged, remove the sterilization indicator from the inside of the tray and make certain that it is the proper color.
ASSISTING WITH MINOR OFFICE SURGERIES AND WOUND CARE PROCEDURES
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PROCEDURE 24-6 Apply Surgical Attire Objective: To apply surgical attire without contaminating the items that should remain sterile.
Equipment/Supplies: ❖ Sterile scrub pack (with brush or sponge/antiseptic soap/nail stick) ❖ Sterile gloves ❖ Sterile gown pack (with sterile towel) ❖ Surgical cap
❖ ❖ ❖ ❖
PROCEDURAL STEPS
RATIONALE
Goggles Mask Sink/running water Paper towels
1. Gather the supplies. 2. Remove all rings and watches and perform an aseptic handwash. Do not replace rings or watches following the aseptic handwash.
Rings and watches should be removed to remove the microorganisms underneath.
3. Place a sterile gown pack on a Mayo stand or clean, dry counter surface near the sink. Open the package containing the sterile gown and towel. Sterile gloves may be transferred or dropped onto the field in a sterile manner; otherwise, sterile gloves should be positioned nearby for easy access once the gown is applied (Figure 24-40).
Opening the sterile gown package with the sterile towel and opening the glove package prior to the procedure will keep you from contaminating hands following the procedure.
4. Apply cap, goggles, and mask.
You apply all nonsterile items before performing a surgical handwash so that you do not contaminate the sterile items following application.
5. Open the sterile scrub pack containing the scrub brush and nail stick. 6. Follow steps 4 through 16 in Procedure 24-1 for performing a surgical handwash. 7. Reach down in the sterile package and lift upward on the folded gown by grasping the inside of the gown below the neckline (Figure 24-41).
The inside of the gown is considered nonsterile because it lies against your body.
8. To provide a wide margin of safety, step away from the table into an area that is unobstructed.
Stepping away from the table or counter will keep you from contaminating the gown when you unfold it.
9. Keeping the inside of the gown toward your body, allow the gown to unfold. Do not touch the outside of the gown with your bare hands. 10. Keeping the hands well above the waist, simultaneously slip both hands into the armholes (Figure 24-42). Do not allow the hands to extend beyond the cuffs.
Hands should not extend beyond the cuffs to prevent them from contaminating the gown.
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FIGURE 24-40
FIGURE 24-41
FIGURE 24-42
FIGURE 24-43
FIGURE 24-44
FIGURE 24-45
Open the sterile gown packet and expose the sterile towel without contaminating it or the other items inside. Sterile gloves may be placed on the tray in a sterile manner.
Reach down in the sterile package and lift upward on the folded gown by grasping the inside of the gown below the neckline.
Keeping the hands well above the waist, simultaneously slip both hands into the armholes.
Have another medical assistant pull the gown up over your shoulders by grasping the inside shoulder and neck seams (keep hands within the cuffed sleeves.) The gown should then be fastened at the neck and waist level in the back only.
Using the outside cuff of your surgical gown from your dominant hand, pick up the glove for your nondominant hand. Lay the glove on the palm side of the outside cuff of the nondominant hand.
With both hands, pinch the rolled edges of the glove and stretch the glove up and over the gown cuff while working your fingers out of the cuff of the gown into the glove.
PROCEDURAL STEPS
RATIONALE
11. Have another medical assistant pull the gown up over your shoulders by grasping the inside shoulder and neck seams. Keep the hands within the cuffed sleeves. The gown should then be fastened at the neck and waist level in the back only (Figure 24-43). Do not allow the medical assistant to touch any part of the gown that is to remain sterile. 12. Using only the outside cuff of your surgical gown from your dominant hand, pick up the glove for your nondominant hand. Lay the glove on the palm side of the outside cuff of the nondominant hand. If correctly positioned, the fingers of the glove should be pointing toward your elbow and the thumb side of the glove should be facing down (Figure 24-44).
Sterile to sterile: Using the outside of the gown to pick up the glove will prevent the glove from becoming contaminated.
13. With both hands still tucked within the inside cuffs of the sleeves, pinch the rolled edges of the glove and stretch the glove up and over the gown cuff while working your fingers out of the cuff and into the glove (Figure 24-45).
If you work your hands through the sleeve before the gloves are on, you will contaminate the gown.
14. Gently slide your fingers into the glove (Figure 24-46). 15. Pick up the second glove by placing the fingers of the gloved hand under the cuff of the second glove (Figure 24-47).
Picking up the opposite glove by placing your fingers under the cuff will assist you in pulling the glove over the cuff of the gown.
ASSISTING WITH MINOR OFFICE SURGERIES AND WOUND CARE PROCEDURES
❖
FIGURE 24-46
FIGURE 24-47
FIGURE 24-48
FIGURE 24-49
FIGURE 24-50
FIGURE 24-51
Gently slide your fingers into the glove, pulling it over your hand.
Pick up the second glove by placing the fingers of the gloved hand under the cuff of the second glove.
Slide the glove over the cuff on the gown on the opposite hand while working your fingers into the glove.
Remember to keep hands above the waist once gloves are applied.
Pass the cardboard tab to the second medical assistant.
Pick up the other loose string attached to the front of the gown and tie both strings at the waist and secure.
PROCEDURAL STEPS
RATIONALE
16. Slide the glove over the cuff of the gown on the opposite hand while working your fingers into the glove (Figure 24-48). Make certain both cuffs are folded over stockinette cuffs.
Allowing the fingers to extend beyond the gown before the glove is applied may contaminate the gown.
17. Remember to keep the hands above the waist once gloves are applied (Figure 24-49).
Hands that drop below the waist may result in contamination to the gloves.
18. Pass the cardboard tab to the second medical assistant (Figure 24-50). Grasp the string attached to the cardboard as the medical assistant pulls the cardboard toward the outside. The cardboard will separate from the string. 19. Pick up the other loose string attached to the front of the gown and tie both strings at the waist and secure (Figure 24-51). 20. Make sure your hands stay above the level of the waist at all times.
Hands are considered contaminated if they fall below the waist.
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PROCEDURE 24-7 Remove an Old Dressing, Irrigate the Wound, and Apply a New Dressing Objective: To correctly remove an old dressing without contaminating the patient’s wound or your gloves and to properly clean the wound and apply a new dressing.
Equipment/Supplies: ❖ ❖ ❖ ❖ ❖ ❖
Waterproof pad Hand cleanser (alcohol-based) Examination gloves Sterile gloves Sterile basins Sterile 4x4s
PROCEDURAL STEPS
❖ ❖ ❖ ❖ ❖ ❖
Sterile water or saline 20-cc syringe Bandage scissors Biohazard container Dressing and bandage material Patient’s chart
RATIONALE
1. Check the patient’s chart to determine the type and strength of irrigating solution and dressing to be used, and gather the supplies.
Today’s guidelines usually suggest irrigating wounds with sterile saline.
2. Identify the patient using two identifiers.
It is important to know that you have the right patient.
3. Identify yourself. 4. Explain the procedure.
Explaining the procedure helps the patient know what to expect.
5. Ask the patient if the patient has had any problems since the surgery and make certain that the patient has been following all home care instructions.
If the patient has encountered problems, the procedure may be postponed.
6. Have the patient expose the area. 7. Place a waterproof pad under the wound area and position so that the work area is easily assessable.
This is to keep the patient and the patient’s clothes dry while irrigating and cleansing the wound.
8. Wash hands using aseptic technique and apply appropriate PPE (nonsterile examination gloves).
The gloves are to protect you from being exposed to exudate when removing the dressing.
9. Inspect the outer covering of the bandage. Make a mental note of any concerns. Was the bandage torn, dirty, or wet?
If the bandage material is dirty or tattered, it could indicate that the patient is not following home care instructions, which could lead to infection.
10. Cut the bandage with a pair of bandage scissors along the side of the wound (Figure 24-52). Carefully remove the bandage and dressing by pulling the bandage toward the wound (Figure 24-53).
Pulling the bandage away from the wound could cause the wound to stretch.
11. Inspect the inner portion of the bandage for any drainage or odor. Make a mental note of your findings. Discard the bandage material into a biohazard container.
The physician will not see the bandage material, so if there are any signs of infection on the bandage, the physician will need to be notified.
ASSISTING WITH MINOR OFFICE SURGERIES AND WOUND CARE PROCEDURES
FIGURE 24-52 Cut the bandage with a pair of bandage scissors along the side of the wound. Carefully remove the bandage and dressing by pulling the corners of the bandage toward the wound.
PROCEDURAL STEPS
❖
FIGURE 24-53 Carefully remove the bandage and dressing by pulling the corners of the bandage toward the wound.
RATIONALE
12. Without touching the wound, look at the wound area and inspect it for any signs of infection, including edema, erythema, drainage, etc. Make a mental note of your findings.
It is important to document any signs of infection for future reference.
13. Remove gloves and wash your hands. Follow office policy regarding having the physician check the wound before redressing.
The gloves were contaminated once they touched the bandage contents.
14. Properly position and clean the Mayo tray with the 4x4s containing disinfectant. Allow the stand to air dry. 15. Place one of the wrapped sterile basins on the center of the Mayo stand. Open using sterile technique.
This basin is for the irrigating solution.
16. Open the peel-apart package containing the sterile 4x4s and drop the contents from the packet onto the field.
The sterile 4x4s will be used to dry the area once the irrigation is done.
17. Open sterile dressing and place it on the sterile field.
Sterile dressing should be used to cover an open wound to reduce the risk of infection.
18. Open the sterile bandage and place it on the sterile field. 19. Drop a sterile 20-cc syringe onto the sterile field.
The syringe will be used to irrigate the wound.
20. Pour a small amount of sterile saline into the sterile basin.
Saline will be used to irrigate the wound.
21. Remove the other sterile basin from the side table and place it on the waterproof drape near the wound. Open it in a sterile manner. Instruct the patient not to touch the basin or drape.
This basin should be sterile to protect your gloves when moving the basin during the procedure.
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continued
FIGURE 24-54 Draw
FIGURE 24-55 Open
up irrigating fluid from the basin with the sterile syringe. Irrigate the patient’s wound, according to the physician’s orders.
the sterile dressing and place over the wound.
PROCEDURAL STEPS
RATIONALE
22. Thoroughly wash your hands using the alcoholbased sanitizer on the side table.
Hands should always be washed prior to gloving to reduce the risks of contamination.
23. Don a pair of sterile gloves.
Because this is an open wound, sterile gloves should be applied.
24. Arrange items on the tray for easy access. 25. Draw up irrigating fluid from the basin with the sterile syringe. Irrigate the patient’s wound so that the water runs into the basin on the sterile field (Figure 24-54).
You don’t want the water to run all over the tray.
26. Dry the wound with sterile gauze.
You do not want to contaminate the area.
27. Open the sterile dressing and place it over the wound (Figure 24-55). 28. Choose a bandaging technique that best suits the patient’s wound.
You want to apply the dressing so that it remains intact.
29. Throw away all trash into proper trash receptacles and give the patient home care instructions and any prescriptions.
The patient must be educated on how to care for the wound for better results.
30. Dismiss the patient and clean the room. 31. Document the procedure.
Document the procedure in order to illustrate what was done for the patient.
DOCUMENTATION EXAMPLE:
04-15-XX 2:30 p.m.
Pt. here for a dressing change following last week’s injury to L arm. Pt. states that the she took all of her antibiotic and dressed wound according to home care instructions. Dressing was clean and dry. A small amount of serosangous exudate present on the inside portion of the bandage. –erythema or edema over the wound area. Irrigated wound with 40 cc of sterile saline. Dried area with sterile gauze. Applied a sterile collagen dressing to the area. Reinstructed pt. on proper wound care. Pt to return next week. Jeanine Ruh, CMA (AAMA)
ASSISTING WITH MINOR OFFICE SURGERIES AND WOUND CARE PROCEDURES
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Chapter Summary The medical assistant has many responsibilities when preparing for and assisting with surgical procedures. Medical assistants should have a good understanding of aseptic technique and develop a sterile conscience so that they can advocate for the patient in instances where there may be a breach in sterility. Providing the patient with good instructions on how to prep for the procedure will help in making certain that the procedure goes forward without any delays. Explaining the procedure beforehand can help to eliminate the patient’s fears and help the patient to relax during the procedure. The delivery of good postop instructions is essential for a good recovery and includes wound care instructions, instructions on how to take medications, and what signs to watch for that may indicate infections. Patients should repeat back the information to ascertain a complete comprehension of the information and should be encouraged to call with any concerns. Educating the patient properly will assist with a speedy recovery and help to get the patient back to a normal lifestyle.
FIELD APPLICATION CHALLENGE You are a new medical assistant at the Bayview Clinic and are about to assist a physician with a minor surgical procedure. You are quite nervous because you have never worked with this particular physician and you are afraid that you will make a mistake. Several minutes into the procedure, the physician asks you to hand her an instrument from the side table. When you do, you accidentally drop the instrument on the floor.
1. Should you pick the instrument up off the floor first or retract a new instrument for the physician? 2. How did your mindset possibly contribute to the incident? 3. How could your mistake affect the physician’s opinion of you?
Chapter Assessment 1. All of the following statements apply to the minor surgery setting except: a. items are either sterile or nonsterile. b. the sterile tray may be set up 30 minutes prior to the start of the procedure. c. handling the outside of sterile packs is permissible. d. do not reach over a sterile field. 2. Which of the following duties should be completed a few days prior to surgery? a. Educate the patient about fasting instructions. b. Inform the patient about the type of clothing to be worn. c. Tell the patient if it will be necessary to have someone to drive the patient home after the procedure. d. All of the above
3. Which of the following statements is true in regards to surgical instruments? a. Sterile items can be used more than once, if the procedures are the same. b. Surgical instruments can be used for other purposes besides surgery. c. A sterile item should not be opened until just prior to use. d. A sterile item may be opened 15 minutes prior to the procedure. 4. Which of the following items would not be considered sterile? a. Cap b. Back of the gown c. Goggles d. All of the above
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5. All of the following are duties of a nonscrubbed medical assistant during a surgical procedure except: a. opening lids of trash receptacles. b. collecting specimens from the physician. c. handing items not on the field to the physician. d. handing items that are on the field to the physician. 6. Whose responsibility is it to clean the postop site and apply a sterile dressing? a. Physician b. Medical assistant c. Patient d. None of the above 7. Which of the following solutions is recommended to clean a wound? a. Hydrogen peroxide b. Iodine c. Alcohol d. Normal saline
2. In what instances should a cleansing with soap and water be performed prior to using the alcoholbased soap? 3. What does the research state about the use of alcohol-based hand cleansers?
CONNECTION Using your StudyWARE CD-ROM: ❖ Complete the Hangman activities for this chapter. ❖ Complete the Quiz for this chapter in Test Mode.
THE DVD LINK On your StudyWARE CD-ROM, go to the DVD Challenge for this chapter. View the DVD clip and respond to the following questions:
8. Which type of dressing absorbs excess fluid from the wound? a. Primary b. Secondary c. Tertiary d. Simple
1. What did you think about Eileen’s personality? Did she make the patient and his wife feel comfortable?
Web Activities
2. What did the patient sign after the physician explained the procedure?
Infection Control Today has many articles related to setting up and assisting with surgeries. Go to their Web site at http://www.infectioncontroltoday.com and place the following words into their search box: hand hygiene and gloves. Find an article that answers the following questions: 1. In what instances can a waterless soap be used to clean hands in a health environment?
3. List at least three items that were placed directly onto the field for the cyst removal tray. 4. List at least three items that were placed on the side table for the cyst removal tray. 5. Do you think that Eileen was a little close to the tray while setting it up?
C H A P T E R
Fundamentals of the Medical Laboratory Chapter Outline Rationale for Laboratory Tests Laboratory Regulations Clinical Laboratory Improvement Amendment (CLIA ’88) Testing Categories Implications of CLIA ’88 for the Medical Assistant Other Accreditation Options for POLs Classifications of Laboratories Reference Laboratory Hospital Laboratory Physician’s Office Laboratory (POL) Point-of-Care Testing (POCT) Procurement Station Laboratory Departments Urinalysis Department Hematology Department
Clinical Chemistry Department Microbiology Department Immunology Department Cytology Department Histology Department Blood Bank Laboratory Personnel Quality Control Quality Assurance Proficiency Testing Safety in the Laboratory Hazards Processing Requests for Laboratory Tests The Laboratory Requisition The Laboratory Report Preparing the Patient for Laboratory Testing
25 Essential Terms assay asymptomatic baseline value centrifuge Clinical Laboratory Improvement Amendment (CLIA ‘88) clinical diagnosis condenser cytology diaphragm differential diagnosis hematology histology hospital laboratory immunology intervals iris diaphragm microbiology normal value objective continues
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KEY COMPETENCIES
CAAHEP
ABHES
Reviewing and Reporting Laboratory Results
III.C.3.b.4.i
VI.A.1.a.4.l
Specimen Collection for Offsite Testing
III.C.3.b.2
VI.A.1.a.4.j
Using the Microscope
ocular physician’s office laboratory (POL) point-of-care testing (POCT) procurement station profile provider-performed microscopy procedures (PPMP) quality assurance (QA) quality control (QC) reference laboratory reference value requisition
General Guidelines for Specimen Collection, Handling, and Transport Specimen Collection The Microscope Parts of the Microscope
Care and Maintenance Types of Microscopes The Centrifuge Operating the Centrifuge
Developmental Objectives After completing this chapter, you should be able to: 1. Correctly spell and define the essential terms. 2. List the reasons for performing laboratory tests. 3. Describe the different classifications of laboratories. 4. List the different departments of the laboratory and at least three examples of the tests performed within each department. 5. Discuss the three levels of testing regulated by CLIA ’88. 6. List the level of testing that the medical assistant can perform in regards to CLIA ’88. 7. Define COLA. 8. Discuss the importance of and the difference between quality control and quality assurance. 9. Explain the need for proficiency testing. 10. List basic safety rules for the laboratory. 11. Correctly complete a laboratory requisition. 12. Discuss the importance of normal reference ranges. 13. Discuss the importance of proper patient preparation. 14. List five general guidelines for proper specimen collection. 15. Label the parts of the microscope and describe their use. 16. List the steps for proper care and maintenance of the microscope. 17. Describe the process of centrifugation.
Introduction The medical laboratory performs a vast array of tests that assist providers in diagnosing, treating, and following the progression of patients with acute and chronic
F U N D A M E N TA L S OF T H E M E D I C A L L A B OR ATOR Y
illnesses. There is a variety of personnel that work in laboratories. Medical assistants may work in an onsite physician’s office laboratory (POL), or may even work in a hospital or reference laboratory performing specific services. The medical assistant’s responsibilities in regards to lab testing may be any of the following: Preparing patients for lab testing, specimen collection and processing, performance of waived or noncomplex lab tests, and sending specimens to outside laboratories. Proper specimen collection and processing is vital to ensure that test results are accurate. Careful specimen collection and handling can make the difference in whether the provider receives timely and accurate results or receives an error message stating that the specimen was rejected and must be collected again. Being familiar with commonly ordered lab tests, rationale for ordering the tests, and normal values for each test can assist the medical assistant with patient education and appropriate test follow-up.
RATIONALE FOR LABORATORY TESTS Laboratory tests are usually ordered in conjunction with other diagnostic tests to assist in diagnosing a patient’s condition. However, there are a number of reasons for requesting laboratory testing. Rationale for lab testing includes: ❖ Determining baseline values: All laboratory values have normal ranges for particular patient populations; however, some patients may run at the lower or higher end of a range. Baseline readings establish a starting point for monitoring a patient’s lab results. These values may be ordered during a complete physical exam or during a first office visit to establish a point of reference for future testing. ❖ For legal purposes: Insurance companies and many employers require individuals to submit to testing for alcohol and drug screenings. Individuals who have been involved in a vehicular accident or who are named in a crime may also be required to submit to testing. Additional legal reasons for laboratory testing include determination of paternity and the screening of pregnant patients for sexually transmitted diseases such as gonorrhea and syphilis. ❖ To screen for pathologic conditions: Sometimes patients present with very vague or general symptoms, while others are asymptomatic (no symp-
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toms at all). Laboratory tests can steer the provider in the right direction when general symptoms alone, such as fatigue, cannot provide a diagnosis. Often times, the provider will order a profile (a group of related tests) to assist with a diagnosis based on vague signs and symptoms. ❖ To confirm a clinical diagnosis: Many times, the provider can arrive at a clinical diagnosis based solely on observing the patient’s signs and listening to the patient’s description of the symptoms. To confirm the diagnosis, the provider will order lab tests. For example, a patient presents with classic symptoms of mononucleosis: swollen lymph nodes, extreme fatigue, sore throat, and low-grade fever. By obtaining laboratory results, the diagnosis can be confirmed. ❖ To obtain a differential diagnosis: Sometimes patients will present with symptoms that can be attributed to more than one disease or condition. Laboratory tests can provide the provider with results that will help him to arrive at a differential diagnosis. An example would be a patient who exhibits signs and symptoms of strep throat. The provider must determine whether or not the patient has a viral or streptococcal infection in order to implement an appropriate treatment plan. ❖ To assess treatment methods and patient progress: Conditions such as diabetes must be followed on a continuous basis. The provider will order a battery of tests at predetermined intervals to follow the progression of a disease and its affects on different
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FI E L D S M A R T S Performing baseline readings not only assists the provider with knowing what is “normal” for a particular patient, but it can also help to forecast future disease. By performing a patient’s baseline readings for tests such as glucose, cholesterol, and blood urea nitrogen (BUN) levels, the provider can determine if the patient is at a higher risk for future diseases such as diabetes, heart attack, or kidney problems. Patients need to understand that a “high normal” may be indicative of future disease. Continuous monitoring and patient education is very important for these individuals.
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organs, as well as to evaluate the effectiveness of a prescribed treatment to determine if adjustments are necessary.
LABORATORY REGULATIONS Health care facilities, including medical laboratories, must adhere to strict rules and regulations. Federal regulations were developed to protect the public by improving the quality of laboratory testing. These regulations govern all facilities and personnel performing laboratory tests on human specimens that are used for diagnosis, treatment, and prevention of disease.
Clinical Laboratory Improvement Amendment (CLIA ‘88) Under the protection of the agency formally known as the Health Care Financing Administration (HCFA) (now referred to as the Center for Medicare and Medicaid Services (CMS) and the Department of Health and Human Services (DHHS)), the Clinical Laboratory Improvement Amendment (CLIA ’88), was enacted by congress as an amendment to the original Act of 1967. CLIA ’88 was created to protect patients by establishing safety policies and procedures. The amendment addresses the issues of quality control, quality assurance, record keeping, and qualifications of personnel performing laboratory testing. In 1988, reports of deaths directly related to misread Pap smears brought about public demand for stringent guidelines to ensure the safety of patients with regard to laboratory testing. CLIA ’88 established such standards for all lab tests in order to ensure test accuracy, reliability, and timeliness, regardless of what type of laboratory performs the test. The regulations consist of four sets of rules: laboratory standards, user and application fees, procedures for enforcement, and approval of accreditation programs. All laboratories are required to register with CLIA regardless of the number or category of tests performed. A laboratory must meet performance essentials based on the complexity of the test method used and risk factors associated with incorrect results. A laboratory enrolling in the CLIA program must complete a registration application, pay fees, be surveyed (if applicable), and become certified. Previously, waived labs (labs that do not perform complex lab testing) and labs that are certified to perform provider-performed microscopy procedures (PPMP) were not subject to routine inspections, but due to the influx of newly waived tests and the poor performance studies of waived labs around the country, CLIA now routinely
inspects 5% of waived labs on an annual basis and when a potentially viable complaint is registered.
Testing Categories Final CLIA regulations were published on February 28, 1992 based on the complexity of the test method—the more complex the test, the more rigid the requirements. CLIA regulations established three test categories: waived testing, moderate complexity (which includes PPMP), and high complexity. Each category of testing has different requirements for personnel performing the testing and for quality control.
Waived Tests Waived tests (low complexity) are simple to perform, require a minimum of quality control and documentation, and a minimum of judgment and interpretation. Many waived tests are available for home use. Medical assistants are permitted to perform waived tests; however, the provider must be able to confirm that test results are accurate and precise and were performed on the appropriate patient sample. Performance of waived tests does not require the laboratory to participate in proficiency testing by outside inspectors or to employ specially trained personnel. The laboratory is required, however, to obtain a Certificate of Waiver in order to perform low-complexity tests. Table 25-1 provides a general listing of CLIA waived tests.
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FI E L D S M A R T S Waived tests must meet one of the following criteria: test system is cleared for home use by the FDA; the test method is simple and accurate; the test is unlikely to produce erroneous results; and if performed incorrectly, the test would pose no reasonable risk to the patient.
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FI E L D S M A R T S If a laboratory test kit is available for testing on serum or whole blood, it is only CLIA waived if performed on whole blood.
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TABLE 25-1 General List of CLIA Waived Tests CLIA WAIVED TESTS* Certain drug levels Cholesterol (total and HDL) Erythrocyte sedimentation rate Fecal occult blood Gastric occult blood Glucose monitoring devices (cleared by FDA for home use) hCG, urine Hgb A1c (glycosolated hemoglobin) Helicobacter pylori antibodies Hematocrit Hemoglobin (single analyte instrument) Infectious mononucleosis antibodies rapid test Ovulation test by color comparison Prothrombin time (PT) Rapid strep test Triglycerides Urine reagent strip testing (qualitative)
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Moderate Complexity Tests Of all tests in the United States including PPMP, 75% fall into the moderate complexity category. Performance of moderate complexity tests requires an understanding of test methodology, quality control, and instrument calibration. Detailed record keeping and proficiency testing are also required. Any laboratory that has a waived certificate may also apply for a PPMP certificate as long as the following criteria are met: ❖ Personnel performing the test must complete appropriate training, either by formal schooling or on-the-job training, per state requirements. ❖ The test must be performed during the patient’s visit by a physician, midlevel provider under the supervision of a physician, or a dentist. ❖ The test must be performed on the actual patient of the provider and the provider must be a member or employee of the practice. ❖ The test must be categorized as moderately complex. ❖ The microscope is the primary instrument used to perform the procedure. ❖ If testing is delayed on the specimen, it could produce inaccurate results. ❖ The test requires limited handling and processing of the specimen.
Vaginal pH
Table 25-2 lists examples of tests that may be performed by a laboratory with a PPMP certificate.
*Please note: This is not a complete listing of all waived tests. For a more complete list, visit the CMS Web site and search for “waived tests.”
TABLE 25-2 PPMP Tests Direct wet mounts Potassium hydroxide preparations Pinworm examinations Fern tests
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Post-coital direct, qualitative examinations, or vaginal cervical mucus
F IEL D S M A R T S
Urine sediment examinations
Manufacturers of test products and instruments may apply for waiver if the manufacturer can prove that certain waiver criteria have been met. Always check to be sure the test kit or instrument your office is using is waived by CLIA.
Nasal smears for granulocytes Fecal leukocyte examinations Qualitative semen analysis (limited to detection of absence of sperm and sperm motility)
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High Complexity Tests High complexity testing is usually performed in laboratories that are subject to federal regulations. Personnel performing high complexity tests are required to have more education and experience than those performing moderate complexity testing. Cytology (Pap smears), cytogenetics, histopathology, and histocompatability are included in this category.
IMPLICATIONS OF CLIA ‘88 FOR THE MEDICAL ASSISTANT The medical assistant must be familiar with the regulations mandated in the CLIA ’88 amendment and must continually monitor any related changes that may occur in the future. Record keeping is an important component of the amendment. The medical assistant may be responsible for collecting and storing this important information. Types of documentation required as a result of CLIA ’88 include: ❖ Personnel credentials: Any licensing, national certifications, or registrations as well as continuing education units (CEUs) acquired by each individual performing lab testing must be kept in each employee’s file. ❖ Employee hepatitis B vaccine records ❖ Equipment maintenance logs for each instrument that include information on calibration, quality control, and quality assurance. ❖ Procedure manual that includes how each test is performed must be available to all employees. Changes should be made as procedures change and the book should be reviewed annually.
OTHER ACCREDITATION OPTIONS FOR POLS The Commission on Office Laboratory Accreditation (COLA) was established in 1988 as a private alternative to assist labs in complying with the CLIA ’88 standards. In 1993, HCFA (now CMS) granted COLA authority under CLIA ’88 to provide accreditation to physician’s office laboratories (POLs) and in 1998, the Joint Commission, formally JCAHO, also recognized COLA as an accreditation program. After establishing itself as an accreditation agency for POLs, COLA expanded its program to include community hospitals, medical facilities, and independent
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C R I T I C A L T H I N K I NG CHALLENGE As a formally trained medical assistant, you know that you are only allowed to perform waived tests. One of the lab technicians is really slammed with work, and asks you if you could read several microscopic urine specimens that she doesn’t have time to read. You have always liked the detective work in the lab and the lab tech has been training you informally to read specimens during down times. You feel really confident about your abilities. 1. Should you read and report the results? Why or why not?
laboratories. Because of this expansion, the Commission on Office Laboratory Accreditation shortened its name to just COLA. COLA provides onsite reviews of laboratory facilities, as well as choices for accreditation, consultation, and education.
CLASSIFICATIONS OF LABORATORIES Laboratories are classified according to their size, the categories of tests performed, and with whom they are affiliated. Many labs are independently owned and located within larger clinics or medical facilities, while others are located in hospitals or providers’ offices. Larger reference laboratories usually have procurement stations located throughout the community for the purpose of specimen collection only. Table 25-3 lists the different classifications and locations of laboratories and the test categories performed by each.
Reference Laboratory The reference laboratory is an independent laboratory with a large service area usually located regionally. Reference laboratories perform most routine laboratory tests along with highly specialized and complex testing not performed in hospital labs. Most reference labs do not have a blood bank department, which is a department in which units of blood and blood products are tested and stored until needed for transfusion. This type of laboratory employs a diverse group of profes-
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TABLE 25-3 Laboratory Classifications TYPE
LOCATION
TEST CAPABILITIES
Reference or independent
Regional/large service area
Complex/expensive specialty tests
Hospital
Within area hospitals
Most tests required by the hospital (this will vary with each hospital)
Physician’s office laboratory (POL)
Within the physician’s office
Common waived tests
Point-of-care testing (POCT)
Bedside or near the patient testing
Rapid tests such as glucose, cholesterol, strep screening
Procurement station/satellite lab
Suburban areas/near isolated medical facilities throughout the community
Specimen collection only
sionals with a wide variety of skill levels and certifications and is staffed around the clock.
Hospital Laboratory Hospital laboratories are located in most hospitals serving metropolitan areas. The larger the hospital, the larger the laboratory. While a wide variety of tests are usually performed “in house” (in the hospital lab), some hospital labs do not have the capability to perform highly complex or specialized testing. The type of testing performed in the hospital lab is determined by the special needs of that particular hospital.
Physician’s Office Laboratory (POL) A physician’s office laboratory (POL) can vary in size from very small to very large. Waived or moderately complex testing may be performed in these labs. The decision whether to become waived or moderately complex will often be based on patient volume, reimbursement percentages, and provider preference. Examples of waived tests performed in the POL include: glucose, hemoglobin and hematocrit, chemical urinalysis, and rapid tests for strep, pregnancy, and mononucleosis. Many waived POLs also have PPMP certification so that the provider can perform microscopic procedures on different specimens. POLs that are moderately complex must have a lab director and follow all guidelines for moderately complex labs. These POLs usually have more complex instrumentation within their labs and are able to perform more types of tests.
Point-of-Care Testing (POCT) Point-of-care testing (POCT), or bedside/near patient testing, has become a necessity due to managed care and the many changes occurring within the clinical laboratory. The intention of POCT is to deliver rapid and accurate results so medical treatment can be promptly implemented. POCT utilizes small instruments that are quick and easy to operate. Most medical personnel can be trained to perform point-of-care testing.
Procurement Station A procurement station, also referred to as a satellite lab, exists solely for the purpose of specimen collection, usually by venipuncture. Patients are often sent to a procurement station from a clinic or provider’s office that does not have the capability to collect specimens. These stations are strategically located throughout the community and in outlying areas for patient convenience. The laboratory associated with the procurement station then picks up specimens and transports them to the laboratory for processing and testing.
LABORATORY DEPARTMENTS Large laboratories are usually divided into different departments, each performing tests that are specific to their area of expertise. Figure 25-1 depicts a breakdown of the different departments found in a typical medical laboratory.
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Administrator Pathologist
Laboratory Manager or Chief Technologist Assistant Laboratory Manager
Hematology
Chemistry
Routine Chemistry
Routine Hematology
Immumohematology/ Immunology
Immunohematology
Microbiology
Specimen Collecting and Processing
Bacterology Parasitology
Coagulation
Special Chemistry
Immunology
Urinalysis
FIGURE 25-1 A breakdown of different departments in a medical lab
Urinalysis Department The urinalysis department performs the physical, chemical, and microscopic analysis of urine. Positive results on particular reagent strip components may require further testing; however, each lab will have its own protocol. For example, a positive test for leukocytes and nitrites will require the specimen to be sent to the microbiology department for a culture.
Hematology Department The hematology department performs studies of the formed elements of the blood, which include white blood cells (WBC), red blood cells (RBC), and platelets. Cell counts are performed to determine the percentage of particular cell types in the blood as well as to observe cell characteristics such as size and shape. Some hematology departments also perform coagulation studies to determine if any bleeding disorders are present.
Clinical Chemistry Department The clinical chemistry department performs assays (tests) on serum, urine, and cerebrospinal fluid, test-
ing for the presence and amount of specific chemical substances like glucose, cholesterol, and electrolytes. Profiles—groups of related tests that provide information about specific organ systems and metabolic functions—are also performed in this department. Profiles can be performed using a small portion of specimen and were developed to organize laboratory tests for ease of ordering.
Microbiology Department Microorganisms are grown and identified in the microbiology department. Providers need to know which pathogen is causing a patient’s symptoms before prescribing the appropriate medication. Once the microorganism is identified, a sensitivity test is performed to isolate which antibiotics will be effective in treating the pathogen. This area of study is known as bacteriology. There can be several subdepartments within the microbiology department itself: ❖ Mycology: Different types of yeasts and molds, known as fungi, are studied. ❖ Virology: Viruses are isolated, identified, and studied.
F U N D A M E N TA L S OF T H E M E D I C A L L A B OR ATOR Y
❖ Parasitology: Fecal specimens are examined for O & P (parasites and their eggs).
Immunology Department The immunology department, sometimes referred to as the serology department, performs tests that evaluate the immune system. Tests are performed to detect antibodies to bacteria and viruses, as well as tests for autoimmune diseases like rheumatoid arthritis and lupus.
Cytology Department The Papanicolaou test or Pap smear is performed in the cytology department. This department performs microscopic examinations of cells to detect early signs of cancers and other diseases.
Histology Department The histology department is responsible for preparing, staining, and mounting frozen tissue samples for biopsies. Once the samples are prepared, they are examined microscopically for the presence of cancer and other abnormalities.
Blood Bank The blood bank is also referred to as the immunohematology department. This area of the laboratory is responsible for typing and cross-matching blood for transfusion. Units of blood are tested to be sure that they are compatible with the patient that will receive them. Transfusing the wrong type of blood can cause a severe reaction and sometimes death. Blood and blood components are separated and stored in the blood bank until needed. This department is also responsible for performing specialized tests to determine unexpected antigen-antibody reactions. Refer to Table 25-4 for common laboratory tests listed by department and the specimen requirements for each.
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CR ITI C A L TH I N K I N G C H AL LEN G E You have just assisted the provider during removal of a suspicious growth from a patient’s face. You prepare the specimen to be sent to the reference lab. 1. Which department will perform the testing on this specimen?
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LABORATORY PERSONNEL A pathologist—a medical specialist who examines tissues, cells, and body fluid specimens for the presence of disease—usually heads an independent laboratory. Professionals with different levels of training comprise the remainder of the staff. Table 25-5 lists the different personnel employed in larger laboratories. Other professionals that work in the lab are medical assistants and phlebotomists. Refer to Table 1-2 in Chapter 1 for educational requirements and credentialing opportunities for both of these disciplines.
QUALITY CONTROL Quality control (QC) procedures are designed to ensure the accuracy and precision of laboratory tests and to discover and eliminate human error. Every laboratory, including physician’s office labs, are required by law to have a carefully performed, documented, and ongoing QC program in place. QC is designed to monitor all aspects of laboratory procedures, including specimen collection and processing, test methodology, and the reporting of test results. It not only monitors the test itself, but also monitors reagents used in testing, equipment, supplies, and personnel. A good QC program should include the following: ❖ A laboratory procedure manual must be developed and must include all pertinent information for each test. ❖ Equipment maintenance records must contain accurate records on all equipment used to test patient samples, including documentation of all troubleshooting activities. ❖ Calibration procedures must be performed on all equipment according to manufacturer’s directions. ❖ Temperatures must be checked daily and recorded in a log. Refrigerators (used to store reagents or patient samples) and incubators are examples of equipment in which temperatures are checked. ❖ All equipment must be maintained according to manufacturer’s recommendations. ❖ Test methods must be double checked before reporting any patient results by performing control samples that have a known value. Control samples that have both a positive and a negative result should also be included where applicable. The control samples must be tested along with patient samples. If results fall within the manufacturer’s acceptable range, patient results can be considered accurate.
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TABLE 25-4 Common Laboratory Tests and Specimen Requirements LABORATORY DEPARTMENT
TESTS PERFORMED
SPECIMEN REQUIREMENTS
Hematology
Complete blood count (CBC): white blood cell count, red blood cell count, differential, hemoglobin, hematocrit, platelet count, and RBC indicies Erythrocyte sedimentation rate (ESR) Prothrombin time (PT), INR, and other coagulation studies
Whole blood and plasma
Urinalysis
Physical: determination of color, clarity, and specific gravity Chemical: determining the presence or absence of substances like glucose, white blood cells, red blood cells, bacteria, bilirubin, urobilinogen, ketones, and protein Microscopic: microscopic examination of urine sediment for the presence of formed elements such as blood cells, crystals, casts, and epithelial cells
Urine collected by the clean-catch method Urine sediment after centrifugation
Clinical chemistry
Glucose, sodium, potassium, chloride, calcium, protein, albumin, globulin, blood urea nitrogen (BUN), creatinine, bilirubin, cholesterol, triglycerides, uric acid, liver enzymes
Blood, usually the serum component Urine Cerebrospinal fluid (CSF)
Immunology or serology
VDRL/RPR: syphilis detection tests, C-reactive protein (CRP), Rheumatoid factor (RA), Mono test, heterophile antibody test, hepatitis tests, HIV testing, antistreptolysin titer (ASO), pregnancy tests
Serum
Blood bank
ABO blood typing, cross-matching of blood and blood products, Rh typing and Rh antibody titer, cold agglutinins, direct coombs
Serum
Microbiology
Growth and identification of many different pathogenic organisms that can cause diseases such as strep throat, pharyngitis, whooping cough, diphtheria, chlamydia, gonorrhea, tetanus, TB, pneumonia
Specimens from any area of the body, such as the throat, a wound, blood, urine, sputum, the urethra, or the vagina
Parasitology
Determining the presence of parasites and their eggs, which can cause diseases such as trichinosis, tapeworm, dysentery, malaria, pinworm, hookworm, scabies, toxoplasmosis, trichomonas
Feces Blood Vaginal fluid
Cytology
Pap smear Chromosome studies
Epithelial specimens Skin scrapings
Histology
Biopsy Tissue analysis
Tissue samples derived from surgical procedures or biopsy procedures
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TABLE 25-5 Laboratory Personnel TITLE
EDUCATIONAL REQUIREMENTS
CERTIFYING AGENCY
JOB RESPONSIBILITIES
Clinical Laboratory Scientist (CLS)
For all titles: BS degree in laboratory science from an institution accredited in laboratory science (requirements may vary)
National Certification Agency (NCA) for Medical Laboratory Personnel
Department supervisor Performs analysis in all departments of the laboratory
American Society for Clinical Pathology (ASCP)
Performs analysis in all departments of the laboratory
Registered Medical Technologist (RMT)
American Medical Technologists (AMT)
Performs analysis in all departments of the laboratory
Clinical Laboratory Technologist (CLT)
International Society for Clinical Laboratory Technology (ISCLT)
Performs analysis in many departments of the laboratory
Medical Technologist (MT)
Department of Health and Human Services (DHHS) Clinical Laboratory Technician (CLT) Medical Laboratory Technician (MLT)
For all titles: AAS in laboratory science or a combination of formal education and work experience
National Certification Agency (NCA) for Medical Laboratory Personnel
For all titles: Qualitative and quantitative testing under supervision
American Society of Clinical Pathologists (ASCP) American Medical Technologists (AMT)
Registered Laboratory Technician (RLT)
❖ Two levels of controls must be tested daily for each test kit and automated instrument. (Levels of control include normal, high, high-normal, low-normal, etc.) Carefully maintained QC records showing consistent and accurate control sample results ensure that test conditions, procedures, and patient results are accurate.
QUALITY ASSURANCE Quality assurance (QA) is a set of policies and procedures designed to ensure the accuracy and reliability of laboratory testing and should include: ❖ Quality control ❖ Orientation of personnel
International Society for Clinical Laboratory Technology (ISCLT)
❖ Documentation of controls in a quality control log (Figure 25-2) ❖ Maintenance checks on all equipment and instruments, such as automated or handheld monitors, centrifuges, microscopes, etc. ❖ Required calibration of instruments ❖ Temperature checks (Figure 25-3) on refrigerators and freezers used to store reagents, test kits, and patient samples ❖ Checking expiration dates on test kits and reagents ❖ Proficiency testing Another component of QA is the development of reference values or normal values. Results will vary depending on test methodology, so this component is very important.
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QUALITY CONTROL LOG FOR GLUCOSE TESTING KLM Diagnostics Glucometer Controls Date
Time
Lot #
Type of Control
Reference
Results
Range
TEMPERATURE LOG Tech
Date
Time
Initials
Refrigerator
Freezer
(35–40°F)
(0–8°F)
Initials
36
1
LM V
1 0 -1 0 -XX 9 :0 0 a .m . 1 9 8 2 9 78478
N o rm a l 8 0 −1 0 0 8 8 m g /d l LM V m g /d l
1 0 -1 0 -XX 8 :0 0 a .m .
10-12-XX 10:00 a.m. 1982978478
Normal
10-12-XX
8:12 a.m.
38
4
CDV
10-13-XX
8:00 a.m.
37
2
CDL
10-14-XX
8:20 a.m.
35
1
KLL
80–100
90 mg/dl
KLL
mg/dl
FIGURE 25-2 An example of a quality control log for glucose
FIGURE 25-3 An example of a temperature log
testing
PROFICIENCY TESTING Proficiency testing is a program designed to evaluate the quality of a laboratory’s performance. It is a form of external quality control. Several times a year, moderate and high complexity laboratories receive specimens from an approved proficiency testing agency. These samples are evaluated along with patient samples using the same test methodology. Results are then forwarded to the proficiency testing agency for evaluation.
SAFETY IN THE LABORATORY Safety is of critical importance in preventing accidents in the lab. Hazards in the laboratory are not only biological in nature but chemical and physical as well. In 1983, OSHA published the Hazard Communications Standard, which it expanded in 1992, with the development of The Occupational Exposure to Hazardous Chemicals in the Laboratory Standard. This law was designed to make employees aware of the risks involved with
exposure to chemicals in the laboratory. Chapter 10 expands on these standards. Health care workers not only handle patient samples but also chemicals, known as reagents. These chemicals can be toxic, corrosive, and even carcinogenic. The use of specialized protective equipment may be required to protect personnel from toxic fumes and vapors from these chemicals. Many of the chemicals used in the laboratory are highly volatile and flammable. Proper storage, handling, and labeling are required. Electrical hazards in the laboratory can be the cause of burns and electrical shocks as well as fire. Caution must be taken when working around laboratory equipment and other sources of electricity. In the event of fire or other emergencies, evacuation routes should be clearly posted and marked. All emergency phone numbers should be clearly posted near each telephone. These numbers should include: 911 or emergency medical services (EMS), police and fire department, hospital emergency room, and poison control center.
F U N D A M E N TA L S OF T H E M E D I C A L L A B OR ATOR Y
HAZARDS Hazards in the laboratory are divided into physical, chemical, and biological categories. Each category requires its own specific set of guidelines for safe handling. Physical hazard cautions include: ❖ Ground all electrical equipment with UL-approved three-pronged plugs. ❖ Do not use extension cords. ❖ Avoid overloading electrical circuits. ❖ Inspect all plugs and cords for possible damage on a regular basis. ❖ Use surge protectors on equipment and computers to protect against electrical power surges. ❖ Before servicing, make sure electrical equipment is unplugged from the power source. ❖ Post signs or labels indicating electrical hazards and high voltage. ❖ Always follow manufacturer’s directions for use of equipment. ❖ Know the location of the eye wash, chemical shower, fire blanket, and fire extinguisher. Chemical hazard cautions include: ❖ Label all bottles of hazardous chemicals. Be sure to include a material safety data sheet (MSDS) for each chemical stored in the lab in the MSDS manual. Sheets should include instructions for proper storage, handling, and disposal of each individual chemical. ❖ Immediately recap bottles containing toxic substances. ❖ Immediately clean all chemical spills following the required protocol established by OSHA. ❖ If skin or eyes are splashed with a chemical, the area should be flushed with water for at least five minutes. ❖ Never mouth pipette any chemicals.
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❖ Use a safety hood (not generally used in POLs) when working with toxic, flammable, or volatile chemicals. ❖ Store flammable or volatile chemicals in a wellventilated area. Figure 25-4 shows some of the labels that help identify the category of a chemical. Biological hazard cautions include: ❖ Wash hands before and after each patient. ❖ Always wear gloves and other PPE. ❖ Follow Universal Precautions. (Refer to Chapter 10 for a complete list of Universal Precautions.) ❖ Do not eat, drink, smoke, or apply cosmetics or contact lenses in the lab. ❖ Disinfect all work surfaces after each procedure.
PROCESSING REQUESTS FOR LABORATORY TESTS It is usually the medical assistant’s responsibility to process the provider’s requests for laboratory tests. Some tests are performed in office while others are sent to outside facilities. In-office tests do not usually require a laboratory requisition form. The request is documented in the patient’s chart along with date and time of specimen collection. Specimens to be sent to an outside lab for testing must be properly collected, processed, and documented in both the patient’s chart and a in a specimen log. A lab requisition form, containing all pertinent information and tests requested, must accompany each specimen.
The Laboratory Requisition A laboratory requisition form is a preprinted form supplied by the contracted laboratory. It provides a listing of the most frequently ordered tests and profiles and contains a section for special test requests. Other sections of the form supply the laboratory with the name and address of the provider ordering the tests and all pertinent patient data.
TOOL BOX FIGURE 25-4 Hazard symbols used on chemicals found in the
F IEL D S M A R T S Promptly report any accident, injury, spill, or equipment malfunction to your immediate supervisor so the appropriate action can be taken. Proper procedures must be followed to be in accordance with OSHA standards.
laboratory
CORROSIVE MATERIALS
TOXIC CHEMICALS
Copyright 2009 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
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A requisition form must accompany each specimen sent to the laboratory and must be accurately completed. Each laboratory supplies its own forms, which may vary slightly from one lab to another. Several tests can be ordered on a single form, which may mean sending more than one specimen container with a single requisition. When sending multiple test specimens from one patient to different departments within a lab, specimens must be divided appropriately and a separate lab requisition form will need to be completed for each department. Figure 25-5 is one example of a laboratory requisition form.
Careful attention to detail is crucial when completing laboratory requisition forms. Mistakes may mean a delay in receiving critical test results. The following information must be accurately completed on the requisition form: 1. Provider information: Name, address, telephone number, and laboratory account number. This information is needed in order to contact the office to report results or to clarify test requests. Some laboratories provide forms that are preprinted with the provider’s information.
FIGURE 25-5 A sample laboratory requisition form
PLEASE LEAVE BLANK
BILL ACCOUNT
AREA
PATIENT
DEPT.
SEE 1
3RD PARTY SEE 2
C-3 REQUEST FORM INSTRUCTIONS
USA Biomedical Labs 957 Central Avenue Heartland, NY 11112
1 FOR PATIENT BILLING, COMPLETE BOX A.
2 FOR 3RD PARTY BILLING, COMPLETE BOX A AND FILL IN DIAGNOSIS, THEN EITHER B, C, or D.
BILL CD
PATIENT NAME (LAST)
(FIRST)
SPECIES
SEX
AGE YRS.
PATIENT ADDRESS
STREET
CITY
STATE
DATE COLLECTED MO. DAY
MOS.
MISC. INFORMATION
DR. I.D.
TIME COLLECTED YR.
MEDICARE:
N7708
# ZIP DIAGNOSIS WELFARE:
PHYSICIAN
CASE NAME:
# PROGRAM:
PATIENT 1ST NAME:
DATE OF BIRTH
MO.
DAY
YR.
ALL CLAIMS INSURANCE
I.D.
SERVICE CODE:
GR. # SUBSCRIBER
RELATION: PHONE
NAME:
STANDARD PROFILES
SINGLE TESTS
2987 (
) Diagnostic (Multi-Chem) Profile
8350 (
) Immunologic Evaluation*
2804 (
) Health Survey (SMA-12)
2814 (
) Lipid Profile A
2824 (
) Executive Profile A
2817 (
) Lipid Profile B
2825 (
) Executive Profile B
2003 (
) Lipid Profile C
2826 (
) Executive Profile C
2805 (
) Liver Profile A
2858 (
) Amenorrhea Profile
2867 (
) Liver Profile B
7330 (
) Anticonvulsant Group
2868 (
) MMR Immunity Panel
2927 (
) Autoimmune Profile
2869 (
) Myocardial Infarction Profile
2801 (
) Calcium Metabolism Profile
2585 (
) Parathyroid Panel A (Mid-Molecule)
2859 (
) Diabetes Management Profile
2586 (
) Parathyroid Panel B (Dialysis)
7701 (
) Drug Abuse Screen
2587 (
) Parathyroid Panel C (Adenoma)
) Drug Analysis Comprehensive
2818 (
) Prenatal Profile A
2819 (
) Prenatal Profile B
(
(S & U or G) (
) Drug Analysis, Qual (U/G)
2820 (
) Prenatal Profile C
7340 (
) Drug Analysis, Quant. (S)
2877 (
) Prenatal Profile D
2022 (
) Electrolyte Profile
(
) Respiratory Infection Profile A
(
) Exanthem Group
(
) Respiratory Infection Profile B
(
) Glucose/Insulin Response
(
) Respiratory Infection Profile C
2871 (
) Hepatitis Profile I
(
) Respiratory Infection Profile D
2872 (
) Hepatitis Profile II
2821 (
) Rheumatoid Profile A
2873 (
) Hepatitis Profile III
2878 (
) Rheumatoid Profile B
2874 (
) Hepatitis Profile IV
2882 (
) T & B Lymphocyte Differential
2875 (
) Hepatitis Profile V
2876 (
) Hepatitis Profile VI
2883 (
) Testicular Function Profile
2879 (
) Hepatitis Profile VII
2832 (
) Thyroid Panel A
2864 (
) Hirsutism Profile
2032 (
) Thyroid Panel B
2865 (
) Hypertension Screen
2833 (
) Thyroid Panel C
Panel
* FROZEN
(B) BLOOD
(P) PLASMA
5165 6555 3015 3041 5163 5166 5164
( ( ( ( ( ( (
) ) ) ) ) ) )
5208 5169 3147 3010 3018 6472 2995
( ( ( ( ( ( (
) ) ) ) ) ) )
2996 3022 3042 6500 6501 3606 3006 3009 3023
( ( ( ( ( ( ( ( (
) ) ) ) ) ) ) ) )
3650 5180 5179 3342 6416 3078
( ( ( ( ( (
) ) ) ) ) )
ABO and Rho (B) (S) Alpha-Fetoprotein RIA (S) Alk. Phosphatase (S) Amylase (S) Antibody Screen ( ) If pos. ID & Titer (S) (B) Antibody ID (B&S) Antibody Titer (B&S) (Previous Pat. #_____________________ ) ANA. Fluorescent (S) ASO Titer (B) (S) Bilirubin, Direct (S) BUN (S) Calcium (S) CEA (RIA) (Plasma Only) CBC with Automated Diff. (Abnormal Follow-Up Studies) (B) (SL) CBC less Diff. (B) Cholesterol (S) CPK (S) Digoxin (S) Digitoxin (S) GGT (S) Glucose (S) Fasting Glucose (P) Fasting Glucose P.P. (P) Hrs. ____________ HDL Cholesterol (S) Heterophile Screen (Mono) (S) Heterophile Absorption (S) Hemoglobin A1C (B) IgE (S) Iron and T.I.B.C. (S)
(U) URINE
(S) SERUM
6526 6525 7941 3019 4132 3026
( ( ( ( ( ( ( 5187 ( 6505 (
) ) ) ) ) ) ) ) )
2992 (
)
4149 4144 5207 5194 5195 3016 3045 3031 3032 2832 3036 4111 5277
) ) ) ) ) ) ) ) ) ) ) ) )
( ( ( ( ( ( ( ( ( ( ( ( (
Neonatal T4 (S) Neonatal TSH (S) Neonatal T4 Blood Spot Phosphorus (S) Platelet Count (B) (S) Potassium (S) Pregnancy Test, (S or U) Premarital RPR (S) Prostatic Acid Phosphatase (RIA) (S)* Protein Electrophoresis (S) IEP if Abnormal ( ) 9085 Prothrombin Time (P)* Reticulocyte Count (B) RA Latex Fixation (S) RPR Rubella H.I. (S) SGOT (S) SGPT (S) T-3 Uptake (S) T-4 (S) Thyroxine Index, Free (T7) (S) Triglycerides (S) Urinalysis (U) Urogenital GC Assay
UNLISTED TESTS OR PROFILES
(SL) SLIDES
FOLD THIS FORM IN HALF SO TEST(S) ORDERED IS CLEARLY VISIBLE
(Rev. 1-84)
E M R A P P L I C AT I O N Many EMR software programs have the ability to interface with outside laboratories. The medical assistant types the information on the lab requisition form in the computer and sends the requisition to the lab electronically. The lab will receive the form ahead of time and can pre-
2. Patient information: Name, address, telephone number, age, date of birth, and gender. Some tests results are influenced by age and gender. 3. Specimen source: The source of the specimen is important to the lab, especially when a visual inspection cannot reveal its source. For example, a swab containing a specimen for a throat culture would be tested differently than a wound specimen. 4. Date and time of collection: Some laboratory tests must be performed within a certain amount of time following collection, while others need to be performed after a period of time has elapsed. Fasting may also be required for some types of testing in order to be accurate. 5. Requested tests: Each test or profile requested must be marked with a check mark or an “X” in the box beside the test name and number. For those tests not listed, additional space is provided to fill in the test ordered. 6. Patient medications: Certain medications can affect results, so it is important for the lab to have accurate information. 7. Clinical diagnosis: It is important to supply the technician performing the laboratory tests with information on the clinical diagnosis of each patient. This information will alert laboratory personnel of the need for further testing, or whether they need to look for a specific pathogen or abnormal analyte level. Diagnostic and procedural codes are also necessary for billing purposes. 8. Results requested: The provider may want a result immediately (stat or ASAP). The time requested for results must be clearly indicated. All specimens sent to outside laboratories should be documented in a special log. This may be referred to as an “outside lab log” (Figure 25-7). The following information should be documented in this log: ❖ Date and time that the specimen was collected ❖ Name of the patient or other patient identifier code
pare for the specimen’s arrival. The lab may also supply the medical office with a special printer (Figure 25-6), which will print a hard copy of the requisition form, along with special labels to attach to the specimen(s).
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F U N D A M E N TA L S OF T H E M E D I C A L L A B OR ATOR Y
FIGURE 25-6 A printer produces a report form directly from the laboratory to the provider’s office.
❖ ❖ ❖ ❖
Tests requested Lab where the specimens were sent Name of the provider requesting tests Initials of person preparing the specimen
This log should be checked daily for tracking purposes. Once the results are sent back to the medical
TOOL BOX
E M R A P P L I C AT I O N Many EMR software programs are able to automatically track outstanding lab results. This alleviates the need to keep an outside lab log. Outstanding tests may be grouped in a variety of ways: by patient, by type of test, and by date.
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OUTSIDE LAB LOG Date and
Patient Name or
Requested
Outside
Requesting
Time of
Identification
Tests
Laboratory
Physician
Specimen
Code
Clinical
Lithopolis
Initials
Results Received
Collection
10-10-XX
Smith, David Q.
10:00 a.m.
CBC, Lipid
LMV 10-11-XX
Profile, Liver Diagnostics Profile, ESR
10-12-XX Leonard, Carter D. PKU, CBC, Cowell FBS
Geraldo
KLL
Diagnostic Laboratory
FIGURE 25-7 An example of an outside lab log that tracks where the specimen was sent
office, the medical assistant or other lab personnel will place a check mark beside the log entry to show that the results have been received. Log entries that do not have checkmarks should be followed up with a phone call to the lab to determine the cause for the delay in reporting.
The Laboratory Report A laboratory report form is received by the provider’s office after testing is completed. Some labs send a computer-generated form directly to the office, via a
special lab printer, while others may send a printed form with handwritten results. Report forms may also reach the office via phone, fax, mail, or lab courier. The format of forms may vary by laboratory. Figure 25-8 shows one example of a laboratory report form. Whatever the format, specific information appearing on the report form will include the following: 1. Laboratory’s name, address, and phone number 2. Provider’s name, address, and identification number
F U N D A M E N TA L S OF T H E M E D I C A L L A B OR ATOR Y
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Service Laboratories 734 Dunlap Street Chicago, IL 60171 Telephone: 312-824-6925 Fax: 312-8245829 Patient:
Samuels, Annette (ID #ICH 041309) Female, Age 22
Referred by: Inner City Health Care Susan Rice #10004086 SAMP COLL: 04/24/__ 10:40 AM TEST
SAMP RECD: 04/24/__ 12:10 PM
RESULTS
REFERENCE RANGE
UNITS
5.0-11.0 3.9-5.3 11.5-13.5 34.0-40.0 79-99 27-32 32-37 11-15 130-400 7-11
X10-3 X10-6 G/DL % FL PG G/DL % X10-3 FL
*
CBC Col: 04/26/ WBC RBC HGB HCT MCV MCH MCHC RDW PLT MPV AUTO DIFF Col: 04/26/
11:30 5.3 4.5 12.8 37.2 83 28 34 13 290 7
(1)
11:30
DIFFERENTIAL (MAN) 11:30 Col: 04/26/ 34 L SEGS 56 LYMPHS H 9 MONOS 1 EOS RBC MORPH RBC NORM URINALYSIS (ROUTINE) Col: 04/26/ 11:31 1.025 SP GRVTY PH 6.5 PROTEIN NEGATIVE GLUCOSE NEGATIVE KETONES NEGATIVE BILIRUBIN NEGATIVE UROBILINOGEN 0.2 E.U./dL BLOOD/HGB NEGATIVE NEGATIVE NITRITE NEGATIVE LEUKOCYTES
(1)
(1) 41-85 15-48 2-15 0-55
% % % %
(1) 1.003-1.030 5.0-8.0 <= TRACE NEGATIVE NEGATIVE NEGATIVE 0.2-1.0 NEGATIVE NEGATIVE NEGATIVE
3. Patient’s name, age, gender, and identification/ accession number assigned by the lab 4. Date the specimen was received 5. Date results were reported 6. Name of tests performed 7. Test results 8. Normal reference ranges Each office will have its own policy for handling patient lab reports and for providing patients with the results. The medical assistant is usually responsible for receiving reports, reviewing the results, checking for abnormal values, attaching the report form to the patient’s chart, and delivering the chart to the provider for review.
FIGURE 25-8 An example of a laboratory report form
TOOL BOX
FI E L D S M A R T S Normal values or reference ranges may vary from one laboratory to the next according to the test method utilized and patient population. It is important to check the ranges listed on the report form with the results. If results are abnormal, those charts should be placed on the provider’s desk for immediate review.
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The laboratory usually flags abnormal results. For example, an increased value will have an “H” beside the results indicating a high value, while a decreased value will have an “L” beside the results indicating a low value. Each office will have its own protocol for handling abnormal results. Some laboratory results are so abnormal they can pose an immediate health threat to the patient. These results are known as critical lab values or panic values. A panic value is usually telephoned to the office by the laboratory and must be given to the provider for immediate review and action. Panic values are handled differently than regular laboratory results due to their urgent nature. Further discussion on how to handle critical lab values can be found in Chapter 6. Once the provider has reviewed the laboratory report, the provider will sign off on the results, usually by initialling them, and write any comments and instructions to be given to the patient. The chart is then returned to the medical assistant who files the report in the chart. Many providers allow their medical assistants to deliver normal results to the patient. In the case of abnormal results, the provider will usually speak to the patient. Procedure 25-1 lists the necessary steps for reporting laboratory results.
PREPARING THE PATIENT FOR LABORATORY TESTING Proper specimen collection is crucial in order to obtain accurate laboratory results. Patients must clearly understand the collection process, especially if they will be collecting the specimen themselves. For example, a 24-hour urine specimen is collected by the patient at home. Clearly, printed instructions should be given to the patient and reviewed before the patient leaves the office. An improperly collected specimen can create a delay in obtaining results due to rejection of the specimen by the laboratory. The patient will again have to
collect the specimen at home or return to the office for another collection. Keep in mind that many patients are apprehensive about what the tests may reveal or may be in pain or feeling very ill and may not hear or understand all the instructions given to them. Medical assistants should give patients a copy of their card in case patients have questions during the collection process.
GENERAL GUIDELINES FOR SPECIMEN COLLECTION, HANDLING, AND TRANSPORT Outside laboratories will provide the medical office with a catalogue or instruction manual of the tests performed at their facility. The catalogue includes information on the correct type of specimen needed for each test as well as proper collection, handling, and transport instructions. It is important to double check specimen information in each catalogue because specimen requirements differ from one lab to another. If there are any questions concerning the type of specimen to be collected, it is best to contact the laboratory directly. Insurance companies contract with different laboratories to perform patient testing. It is not unusual for several labs to pick up specimens at one office; therefore it is important to be sure that the specimen is sent to the correct facility. If the patient must go to an outside laboratory to have a specimen collected, there are usually satellite labs or procurement stations conveniently located throughout the community.
Specimen Collection The following guidelines apply to most specimen collections. Specific specimen collection techniques will be discussed in related chapters. ❖ Verify the provider’s orders. ❖ Verify specimen requirements in the laboratory instruction manual.
E M R A P P L I C AT I O N EMR programs that interface with outside laboratories allow the lab to send results back and automatically file them in the patient’s electronic record. The provider then receives a listing of all the results sent throughout the day in his
electronic task box. Any abnormal results are usually flagged. Electronic technology allows test results to be displayed in a variety of ways including chronologically, abnormal results only, or even in a graph format.
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PAT I E N T T U T O R for proper preparation. Written instructions are best. Review the instructions with the patient and family members, if present. Ample time should be allowed for any questions the patient may have. Try to ensure that the patient understands the instructions before the patient leaves the office.
TOOL BOX
TOOL BOX
F IEL D S M A R T S
C R I T I C A L T H I N K I NG CHALLENGE
Patients will often ask to have lab tests performed at a facility that is close to their home. Prior to scheduling lab testing, you should check to determine if the requested lab is a participating provider with the patient’s insurance company. If there is no affiliation, you will need to explain why the requested lab cannot be used.
❖ Complete a laboratory requisition with all pertinent information, including tests requested. ❖ Assemble necessary equipment. ❖ Label all specimen containers prior to collection with patient’s name, the date, the time of collection, the medical assistant’s initials, and any other information required by the lab. ❖ Identify the patient using two identifiers and explain the procedure.
It is very difficult to obtain a blood specimen from a particular patient and the provider suggests sending the patient to a procurement station. The patient asks you to recommend one where the “phlebotomists are good.” 1. How will you respond?
❖ Properly collect the specimen following Universal Precautions. ❖ Properly process and store the specimen, preserving the integrity of the specimen until the testing process can be completed. Procedure 25-2 lists step-by-step instructions for specimen collection for offsite testing.
F IELD SM A RTS Differing opinions exist about when to label specimen collection containers. Some believe that in the busy environment of the medical office, it is advisable to label all specimen containers prior to collection to eliminate the possibility of forgetting to label the specimen. You may be called away after collecting a specimen and if the container is not labeled, the specimen
607
may not be able to be properly identified and sent for testing. There are others who have a differing opinion and feel that if the tubes are labeled ahead of time and then not used, they must be discarded. There is no hard and fast rule concerning this dilemma—you should follow the protocol of the facility in which you work.
TOOL BOX
Patients must have a clear understanding of the preparation guidelines for specific laboratory tests. Fasting—not eating or drinking for a specified period of time prior to specimen collection—is often required to obtain accurate test results. Certain foods and medications must be avoided because they can adversely affect the test results. Give the patient clear instructions
❖
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THE MICROSCOPE The microscope is a valuable piece of equipment in the laboratory. It is utilized to view objects like blood cells, microorganisms, and urine components that cannot be seen with the naked eye. The microscope is an expensive piece of equipment that requires proper use and maintenance. Any service or maintenance performed on the microscope must be recorded in a maintenance log. This log should be available for viewing during a laboratory inspection. The medical assistant should be able to identify the parts of the microscope, explain their function, and demonstrate their proper usage and care. There are different types of microscopes, but the most common type used in the POL is the compound microscope, which is named for its two different lenses (Figure 25-9). One lens increases the magnification produced by the other lens.
Parts of the Microscope Each part of the microscope has a unique function. A health care professional using the microscope should be familiar with each part and its function. A listing of each part and its function follows. Refer to Figure 25-9 for the location of the different parts. ❖ Base: Supports the upper components of the microscope ❖ Arm: Used to carry the microscope ❖ Stage: Large, flat plate or platform that holds the specimen slide to be viewed. The slide is held in place with a spring-loaded device called the stage clip. The stage can be stationary, which means the slide must be moved by hand, or mechanical, which means the slide can be moved forward, backward, and side-to-side by using the mechanical stage knobs. The stage has a hole in the center
TOOL BOX
FIGURE 25-9 An example of a binocular compound microscope
❖ ❖
❖
F IEL D S M A R T S Using the microscope can be difficult at first. Learning to focus and adjust the light source takes practice. You can and should become proficient in its use. The provider will often ask the medical assistant to prepare and set up a specimen for viewing on the microscope to save time. Once the specimen is set up, the provider only has to look into the microscope to view the slide.
❖
❖
that allows the light to pass from the light source through the specimen. Illuminator: Located in the base, consisting of a light bulb and an on-off switch. The light passes through the condenser to the slide. Condenser: Located under the stage, it concentrates, directs, and focuses the light from the illuminator on the object being viewed. The condenser can be moved up or down by using the control knob, which will increase or decrease the intensity of the light. Diaphragm: Located within or beneath the condenser, the iris diaphragm, which resembles the iris of the eye, can be opened or closed to increase or decrease the intensity of the light. Coarse and fine adjustment knobs: Located on either side of the arm, the coarse adjustment knob is used to initially bring the specimen into focus and the fine adjustment knob is used to fine tune the focus to produce a clear, sharp image. Objectives: There are three objectives, or lenses, attached to the revolving nosepiece. The lowpower objective magnifies by a power of 10 (indicated as “10x”) and is the shortest lens. The
F U N D A M E N TA L S OF T H E M E D I C A L L A B OR ATOR Y
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high-power objective has a magnification of 40x, and the oil immersion objective has a magnification of 100x. The oil immersion objective is the longest of the lenses. A drop of clear immersion oil is placed on the slide for viewing when using this objective. ❖ Ocular/eyepiece: Microscopes are equipped with either one eyepiece (monocular) or two eyepieces (binocular). The width of the eyepieces of a binocular microscope can be adjusted to fit each individual user. Each ocular contains a lens with a magnification power of 10x. Thus, the total magnification of an object is obtained by multiplying the ocular magnification by the objective magnification. For example, on low power, the magnification is 100 times (10 ⫻ 10).
Care and Maintenance The microscope is an expensive and delicate instrument that can be easily damaged if not handled and used properly. Proper care and maintenance will lengthen the life of the microscope. Following these guidelines will help to maintain the microscope and guarantee its longevity: 1. Always carry the microscope by lifting it by the arm and placing the other hand under the base for support. The microscope is top heavy and carrying it by this method will ensure that it is moved safely from one location to the next (Figure 25-10). 2. Keep the microscope covered with a plastic dust cover when not in use. 3. Clean all lenses with lens paper. Using tissues, paper towels, or gauze could scratch the lenses. 4. Enamel surfaces should be cleaned with mild soap and water and dried with a soft cloth. The oil immersion objective and the stage should be wiped off after use to remove any oil residue. 5. A malfunctioning microscope should be repaired by a qualified service technician.
FIGURE 25-10 The medical assistant demonstrates the proper way to carry a microscope.
The phase-contrast microscope is used for viewing specimens that are unstained or transparent, while the fluorescent microscope is designed to view specimens that have been stained with a special fluorescing dye. Objects viewed through this type of microscope appear as bright objects against a dark background. The electron microscope (Figure 25-11) is a very large and expensive piece of equipment. Special skills and training are required to operate this type of microscope. Because of its size, the electron microscope is usually found only in regional and hospital laboratories. A very small organism such as a virus can be enlarged and viewed in three-dimensional detail. Figure 25-12 shows blood cells seen through an electron microscope.
Types of Microscopes
THE CENTRIFUGE
There are several types of microscopes used in different areas of the laboratory. They range in size from the compound microscope, which is relatively small, to the electron microscope, which is several feet tall and requires special training to operate. The compound microscope is the one most commonly used in the medical office. It is so named because the image is compounded by the use of two different lenses. One lens increases the magnification of the other. The first lens is located in the objective while the second lens system is in the ocular or eyepiece.
The centrifuge is an instrument that spins tubes at high speeds to separate the liquid portion of the sample from the solid portion. By spinning a tube containing a sample in a centrifuge, the different components separate into layers. For example, when centrifuging a urine sample, the heavier solid matter found in the urine is concentrated in the bottom of the tube. The lighter liquid portion is then poured off and the solid matter is examined under the microscope. Spinning a tube of blood in the centrifuge will separate the blood into several layers with the red blood cells in the
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bottom, the serum or plasma on top, and the white blood cells and platelets in the middle. The medical assistant will use the centrifuge to process samples to be sent to outside laboratories for testing. There are different sizes of centrifuges for different uses. Figure 25-13 shows a centrifuge used to spin blood or urine tubes. An example of a microhematocrit centrifuge can be found in Chapter 28.
Operating the Centrifuge Several different models of centrifuges are available from various manufacturers. Medical assistants should always follow the manufacturer’s directions for operation of the model in their office. The following are general guidelines that apply to the operation of any centrifuge:
FIGURE 25-11 A large electron microscope
❖ Use only the type of tube designed for that specific centrifuge. ❖ To prevent creation of an aerosol contamination, spin tubes with caps securely in place. ❖ Always balance the centrifuge by placing tubes with an equal amount of sample across from one another. If centrifuging only one tube, balance with a tube of water. ❖ Secure the lid of the centrifuge before operating. ❖ Allow the centrifuge to come to a complete stop before opening the lid. ❖ Always clean and disinfect all surfaces after any tube breakage or spill.
FIGURE 25-13 Centrifuge used to spin tubes of urine and blood
FIGURE 25-12 Red blood cells as they appear under an electron microscope
TOOL BOX
F IEL D S M A R T S Always wear gloves when operating a centrifuge. Both inside and outside surfaces may be contaminated with blood, body fluids, or OPIM. Nonvisible contaminates can pose an exposure threat to the health care worker.
F U N D A M E N TA L S OF T H E M E D I C A L L A B OR ATOR Y
❖
PROCEDURE 25-1 Review and Report Laboratory Results Objective: To check laboratory test results for abnormal values and relay results to the provider for review.
Equipment/Supplies: ❖ Laboratory report form
❖ Patient’s chart
PROCEDURAL STEPS
RATIONALE
1. Review the laboratory report form, verifying all patient and provider information.
Be sure you have all related forms and that the report belongs to the correct patient.
2. Verify that all tests ordered were performed.
Missing results may indicate the specimen was lost.
3. Check the test results with laboratory reference ranges and flag any abnormal results according to office protocol.
Abnormal results should be brought to the provider’s attention so that they are not overlooked.
4. Immediately report panic values to the provider.
Panic values could indicate a life-threatening medical condition requiring immediate medical intervention.
5. Attach the report form to the patient’s chart and place the chart on the provider’s desk for review.
The provider must review all results, even normal results, before they can be reported to the patient.
6. After the provider has reviewed the results, check to see if there are any special instructions before filing the report form in the patient’s chart.
The provider may want you to call the patient with special instructions.
7. Report the results to the patient according to office protocol.
The medical assistant will usually report normal results to the patient after review by the provider. The provider will usually be the one to discuss abnormal results with the patient.
PROCEDURE 25-2 Specimen Collection for Offsite Testing Objective: To provide the laboratory with the best quality specimen and a lab requisition form that contains all pertinent information.
Equipment/Supplies: ❖ Laboratory requisition form ❖ Necessary collection equipment ❖ Proper specimen containers
❖ Gloves ❖ Sharps container ❖ Patient’s chart continues
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continued
RATIONALE
PROCEDURAL STEPS 1. Verify the provider’s order in the patient’s chart.
Always check to be sure the specimen collection matches the provider’s orders.
2. Review the requirements of the laboratory for specimen collection and transport.
Requirements may vary by lab. Always check the catalogue to prevent errors in collection and handling of the specimen.
3. If the patient is collecting the specimen at home, provide the patient with any special preparation instructions, such as fasting, diet or medication restrictions, and home collection instructions.
Improper preparation by the patient can result in inaccurate results and the need to collect the specimen again.
4. If collecting the specimen in-house, complete the lab requisition with all important information before collecting the specimen (Figure 25-14).
A completed requisition provides the lab with essential information necessary to complete the testing process.
5. Assemble the proper equipment.
Appropriate containers must be used as specified by the lab to ensure specimen integrity.
6. Label all specimen tubes and containers with the patient’s name, the date and time of collection, your initials, and any other information required by the lab.
Properly labeled containers prevent specimen mix-ups.
7. Wash your hands and put on the required PPE.
Both the specimen and the medical assistant should always be protected from contamination.
8. Identify the patient using two identifiers, identify yourself, explain the procedure, verify fasting compliance, and properly collect the specimen according to lab directions.
Providing the lab with the best quality specimen prevents delays in the testing and reporting process.
9. Process the specimen properly and prepare and store it for transport to the offsite lab. Be sure to include the requisition with the specimen.
Improper storage of the specimen prior to pickup could damage the specimen and cause erroneous results.
FIGURE 25-14 A completed lab requisition form must accompany every specimen to the laboratory.
10. Properly dispose of wastes, and document the procedure in the patient’s chart and the appropriate lab log.
DOCUMENTATION EXAMPLE:
04-01-XX 1:10 p.m.
Venipuncture—R. arm antecubital area for blood glucose and potassium levels per Dr. Kelly. Verified pt. fasting. 1 red top and 1 gray top picked up by courier for Lab, Inc. 04-01-XX. Trey Miller, CMA (AAMA)
LABORATORY SPECIMEN LOG: DATE
TIME COLLECTED
PATIENT NAME
TEST ORDERED
ORDERED BY
SPECIMEN SENT TO:
INITIALS
04-01-XX
1:10 p.m.
Brown, John
FBS and K
Dr. Kelly
Lab, Inc.
TM
F U N D A M E N TA L S OF T H E M E D I C A L L A B OR ATOR Y
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PROCEDURE 25-3 Use the Microscope Objective: To correctly use and maintain the microscope and to become proficient in the use of the coarse and fine adjustments as well as all objectives.
Equipment/Supplies: ❖ Microscope ❖ Lens paper ❖ Specimen slide
❖ Immersion oil ❖ Tissue
PROCEDURAL STEPS
RATIONALE
1. Wash your hands, apply gloves, and assemble all the equipment.
Gloves must be worn to protect the user from possible exposure to materials that may be present on the microscope or specimen slide.
2. Clean the oculars and the objectives with lens paper (Figure 25-15).
Lenses may be soiled from the previous user. Clean lenses produce a clearer, sharper image.
3. Turn on the light source and adjust the light to a low level.
Low light intensity helps to prolong the life of the bulb.
4. Rotate the nosepiece to the low-power (10x) objective and click it into place.
Initial focusing is accomplished using the low power (10x) objective.
5. Place the specimen slide on the stage and move the stage upward using the stage adjustment knobs, so the low-power objective is in its lowest position. Observe the stage movement so that the objective does not come in contact with the slide (Figure 25-16).
The slide could be damaged if the objective strikes the slide.
6. Adjust the eyepieces to a comfortable width. View the slide through the oculars, and using the coarse adjustment knob, bring the specimen into focus (Figure 25-17).
Initial focusing is accomplished using the coarse adjustment knob only.
FIGURE 25-15 Lens paper is used to clean the oculars of the microscope.
FIGURE 25-16 The specimen slide is placed on the stage of the microscope. FIGURE 25-17 The microscope must be focused to make the image crisp and clear.
continues
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continued
PROCEDURAL STEPS
RATIONALE
7. Adjust light intensity as needed.
The light intensity must be correct in order to properly view the specimen. Light that is too bright may shine through certain objects, making them invisible. Light that is too dim may make some items impossible to see.
8. Using the fine adjustment knob, bring the specimen into sharp, clear focus.
As the specimen slide is moved on the stage, the image seen will become blurry and must be refocused.
9. Lower the stage and rotate the nosepiece to the high-power objective (40x). Click it into place and bring the slide into focus.
The high-power objective is longer, so the stage will need to be lowered to keep from damaging the slide.
10. If using the oil immersion objective, rotate the nosepiece so that the (100x) objective is off to the side and place a drop of oil over the center opening of the stage (Figure 25-18).
Immersion oil helps with magnification of the object being viewed with the (100x) objective.
11. Rotate to the oil immersion objective and click it into place. Be sure that the objective is sitting in the drop of oil. Caution: Do not rotate the highpower (40x) objective through the drop of oil.
The high-power objective is not designed for use with immersion oil. Dragging the high-power objective through the oil can damage the objective.
12. Using the fine adjustment knob, bring the specimen into sharp focus. Adjust the light to bright intensity.
Bright light is needed for clear observation of the specimen.
FIGURE 25-18 A drop of immersion oil is placed on the slide for clearer viewing.
13. After observation of the specimen is complete, rotate the objective to the side and remove the slide from the stage. 14. Clean the objective with lens paper and wipe the stage clean with tissue or gauze (Figure 25-19).
15. Turn off the light source and cover the scope with a protective dust cover.
Objectives should be cleaned immediately to prevent oil from collecting and drying on the lens. Turning off the light source between uses helps to prolong the life of the bulb. Keeping a cover on the scope between uses prevents a buildup of dust and debris.
FIGURE 25-19 The objective lenses must be cleaned with lens paper after each use to prevent damage.
F U N D A M E N TA L S OF T H E M E D I C A L L A B OR ATOR Y
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Chapter Summary The medical laboratory is extremely valuable to the provider in reaching an accurate diagnosis for many patient conditions. Without laboratory test results, the provider would only be able to arrive at a tentative diagnosis based on patient signs and symptoms. With the implementation of many waived tests, the medical office can now perform a variety of tests at the point of care. Quicker results mean quicker treatment for the patient and faster relief. The role of medical assistants in laboratory testing is an important one. They must be able to perform inoffice tests accurately, prepare patients for testing, collect and process specimens, and send specimens to outside laboratories.
FIELD APPLICATION CHALLENGE The provider requests a blood glucose and a potassium level on a patient. The patient must fast for the blood glucose level to be accurate. After referring to the lab catalogue for specimen requirements, you learn that you must provide the lab with serum. The serum must be clear with no hemolysis for the potassium level to be accurate. The patient states she had some water when taking her morning medications, but nothing else to eat or drink. You have difficulty drawing the patient’s blood and the tube fills slowly. After centrifuging the blood, you notice that the serum has a slight red tinge to it,
which indicates hemolysis. The patient has already left the office, so you send the specimen sample for testing. 1. Should you have sent the specimen to the lab, knowing that the serum was hemolyzed? 2. Will the specimen be viable for accurate results? Why or why not? 3. If the lab rejects the specimen, what will be the next logical step?
Chapter Assessment 1. Lab tests are performed to: a. obtain a baseline value. b. diagnose a disease. c. confirm a clinical diagnosis. d. all of the above. 2. Tests that the medical assistant can perform in the POL are known as: a. waived tests. b. CLIA ’88. c. proficiency testing. d. non-waived tests. 3. The medical assistant’s responsibilities in laboratory testing include all of the following except: a. having a working knowledge of normal reference ranges. b. proper patient preparation. c. specimen collection. d. performing waived and moderately complex lab testing.
4. The form that accompanies all specimens to the lab is the: a. report form. b. lab specifications form. c. lab requisition form. d. data form sheet. 5. The microscope most commonly used in the POL is the: a. phase contrast. b. electron. c. compound. d. fluorescent. 6. The analysis of abnormal cells is performed in which department of the laboratory? a. Hematology b. Serology c. Microbiology d. Cytology
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7. All microscope lenses should be cleaned with: a. acetone. b. tissue. c. gauze. d. lens paper.
Web Activities
THE DVD LINK On your StudyWARE CD-ROM, go to the DVD Challenge for this chapter. View the DVD clip and respond to the following questions:
1. Visit http://www.aafp.com for information on quality control and quality assurance.
1. What is the main agency that primarily oversees CLIA?
2. Visit the following Web site for more recent information on CLIA ’88: http://www.cdc.gov/mmwr/ mmwrsrch.htm
2. What category of testing is the medical assistant typically able to perform? 3. Besides documenting lab information in the patient’s chart, where else is lab information documented? Why?
CONNECTION Using your StudyWARE CD-ROM: ❖ Complete the Concentration and Crossword Puzzle activities for this chapter. ❖ Complete the Quiz for this chapter in Test Mode.
C H A P T E R
Collecting the Blood Sample Chapter Outline Why Do We Collect Blood? Venipuncture Equipment and Supplies Vacuum Tube System Multisample Needles Holders and Adapters Vacuum Tubes Winged Infusion (Butterfly) System Blood Collection Tray Performing the Venipuncture Assembling Equipment and Supplies Identifying the Patient Positioning the Patient Selecting the Site Specimen Collection by the Syringe Method Specimen Collection by the Vacuum Tube Method
Specimen Collection by the Butterfly Method Patient Response and Complications The Failed Venipuncture Criteria for Specimen Rejection Improper Labeling of Specimen Tubes Use of Incorrect Specimen Tubes Incorrect Collection Time Incorrect Specimen Handling Hemolyzed and Lipemic Specimens The Capillary Puncture Equipment Common Sites for Collection Preparing the Site Collecting the Specimen Order of Draw General Guidelines for Specimen Handling
26 Essential Terms additive aliquot antecubital space anticoagulant butterfly capillary puncture constrict evacuated tube gauge hematoma hemoconcentration hemolysis integrity lancet lipemia palpate phlebotomist phlebotomy plasma primary container quantity not sufficient (QNS) serum continues
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KEY COMPETENCIES
CAAHEP
ABHES
Venipuncture (Syringe Method)
III.C.3.b.1.d III.C.3.b.1.e III.C.3.b.2.a
VI.A.1.a.4.j VI.A.1.a.4.q VI.A.1.a.4.r
Venipuncture (Vacuum Tube Method)
III.C.3.b.1.d III.C.3.b.1.e III.C.3.b.2.a
VI.A.1.a.4.j VI.A.1.a.4.q VI.A.1.a.4.r
Venipuncture (Butterfly Method)
III.C.3.b.2.a
VI.A.1.a.4.j VI.A.1.a.4.s
Performing a Capillary Puncture
III.C.3.b.1.d III.C.3.b.1.e III.C.3.b.2.b
VI.A.1.a.4.j VI.A.1.a.4.q VI.A.1.a.4.r VI.A.1.a.4.t
thixotropic separator gel tourniquet vacuum tube venipuncture winged infusion
Developmental Objectives After completing this chapter, you should be able to: 1. Correctly spell and define essential terms. 2. List the different types of equipment used to perform venipuncture when using a syringe, vacuum tube method, and butterfly. 3. Name the additives contained in each of the tube top colors and state their functions. 4. List the equipment found in a well-stocked blood collection tray. 5. List the general steps for performing a venipuncture. 6. Explain the importance of proper patient education when performing the venipuncture. 7. List the order of draw for both the capillary puncture and venipuncture. 8. List the possible causes of a hemolyzed specimen. 9. List the different patient responses to a venipuncture and the appropriate action for each. 10. List the reasons for a failed venipuncture. 11. Explain the different criteria for specimen rejection. 12. Explain the rationale for performing capillary puncture versus venipuncture. 13. List the general guidelines for specimen handling.
Introduction Phlebotomy is the name given for the procedure of collecting blood samples. Each health care facility will have specific professionals (phlebotomists) designated to perform phlebotomy. In many health care settings, the medical assistant will be the health care worker that collects blood samples.
COLLECTING THE BLOOD SAMPLE
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Proper collection techniques must be followed to ensure that the laboratory receives the highest-quality specimen for testing. An improperly collected blood specimen can lead to inaccurate results that can, in turn, lead to a misdiagnosis. Correct procedures for performing venipuncture and capillary puncture will be discussed in this chapter. Each method requires training and lots of practice. Proper specimen collection is critical for obtaining accurate test results.
VENIPUNCTURE
WHY DO WE COLLECT BLOOD?
Equipment and Supplies
As blood is circulated throughout the body, it transports oxygen, carbon dioxide, nutrients, waste products, and hormones throughout the body. Because of its role in transporting these components, a multitude of information can be obtained by analyzing the blood to determine the number and type of cells present and the amounts of different types of elements such as electrolytes, cholesterol, and glucose. Every system in the body can be evaluated by performing an analysis of the blood and quantifying specific chemical components. The provider uses information obtained from this analysis to establish baseline values for patients and to diagnose disease states. Information provided by the laboratory is only as good as the specimen received for testing. It is critical that the specimen be obtained by following the proper procedure.
Specialized equipment is necessary to perform each method of venipuncture. Using the right equipment is essential to obtain the best possible specimen.
TOOL BOX
F IEL D S M A R T S The majority of states do not require licensure to perform phlebotomy; however, many hospitals and ambulatory care centers have both educational and certification requirements because of their professional liability coverage. Some hospitals and laboratories will accept the phlebotomy training that medical assistants receive during their training program. Others will require the medical assistant to have phlebotomy certification from one of the agencies that certify phlebotomists. Refer to Table 1-2 for ways that you can become certified as a phlebotomist.
Venipuncture is an invasive procedure in which a vein is punctured to obtain a blood sample. It can be performed using any of the following types of equipment: vacuum tube or evacuated tube and holder, syringe, or butterfly and related equipment. Venipuncture requires special equipment, training, and supervision. Practice makes the medical assistant proficient at venipuncture and helps to make the procedure less painful for the patient.
Tourniquets A tourniquet is applied to the patient’s arm 3 to 4 inches above the puncture site to constrict blood flow and enlarge the veins. This makes the veins easier to palpate, or feel. The tourniquet must be tight enough to decrease venous blood flow to the area, but not so tight that it affects arterial blood flow to the area. Several different types of tourniquets are available for use and can be purchased in both pediatric and adult sizes. The most common type used is a flat latex strap approximately 15 to 18 inches in length (Figure 26-1). Latex is inexpensive and disposable but can also be cleaned if it becomes contaminated with blood. Vinyl
TOOL BOX
PATIENT TUTOR It is important to fully explain the venipuncture procedure to the patient, especially if it is the patient’s first time having blood drawn. Whenever possible, instruct the patient before the day of the appointment to drink lots of water prior to the appointment. This will assist in making the patient’s veins more prominent. Answer all patient questions honestly. Try to put the patient at ease. Many patients are concerned about the amount of blood being drawn. Explain to the patient that there are several pints of blood in the body and that the blood you are taking will automatically be replaced in just a few hours.
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TOOL BOX
SITE CHECK As a safety inspector for a large waste company, I frequently perform mock OSHA inspections for health care facilities. I always check to be sure that the employer is providing employees with safety needles. The safety features must shield the needle after use by providing immediate containment of the needle and must provide a barrier between the hands of the person drawing blood and the used needle. The safety features must also allow the users to contain the needle with a onehanded technique, which keeps the user’s hand behind the needle at all times.
FIGURE 26-1 One kind of tourniquet
tourniquets are available for patients with latex sensitivity. A stretchable band with Velcro attached may also be used. This type is easy to apply, but difficult to clean. If it becomes contaminated with blood, it usually is discarded. A third type of tourniquet consists of a stretchable band with a buckle attached that can be slowly released and tightened if necessary. Figure 26-2 shows the proper way to tie a flat latex tourniquet to the patient’s arm.
Needles The different types of needles used to perform venipuncture include multisample needles for use with the
evacuated tube system, hypodermic needles for use with a syringe, and winged infusion (butterfly) needles used for both systems (Figure 26-3). OSHA regulations require needles to have safety features to decrease the chances of accidental needlesticks. Refer to Figure 26-4 for examples of safety needles. Needles are individually wrapped in sterile packaging, disposable, and designed for a single use only. Hypodermic needles (needles that attach to a syringe) and butterfly needles (smaller needles used typically
FIGURE 26-2 Applying a tourniquet: (a) Keep the tourniquet flat and wrap it around the arm 3 to 4 inches above the puncture site. (b) While stretching the tourniquet tight, cross one end over the other. (c) While keeping tension on the ends and keeping the tourniquet tight, tuck one end under the other. (d) Check to be sure the tourniquet is tight enough so it won’t loosen. The ends should point up and not hang down over the puncture site.
(a)
(c)
(b)
(d)
COLLECTING THE BLOOD SAMPLE
FIGURE 26-3 Different types of needles used to perform venipuncture: multisample needle, hypodermic needle for use with a syringe, butterfly needle for use with a syringe or vacuum tube system
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621
FIGURE 26-5 A multisample needle used with a vacuum tube collection system is sealed until ready to use.
Shaft Lumen Hub Bevel
FIGURE 26-6 The parts of a hypodermic needle
FIGURE 26-4 Examples of safety needles
for hand sticks) are packaged in sterile pull-apart packages. Multisample needles (needles that allow several tubes to be drawn during one blood draw) are sealed in a tube with a twist-off cap that covers both ends of the needle (Figure 26-5). Needles are designed with a beveled point and have a silicon-coated shaft to facilitate easy penetration of the skin. Parts of the needle include the bevel (slanted tip), shaft, lumen (internal core), and hub (attaches to collection system). Figure 26-6 shows the different parts of the needle. Needles are available in a variety of sizes and are classified by their gauge and length. The gauge is a number that indicates the diameter of the lumen: the larger the number, the smaller the diameter. The gauge of the needle will be determined by the amount of blood to be withdrawn, the size and condition of the patient’s vein, and the procedure used to perform the phlebotomy. The usual range of gauges for phlebotomy is 21G to 23G; however, when working in a blood donation center, a 16G needle may be used because
of the amount of blood being taken from the patient. See Table 26-1 for a listing of needle gauges used for venipuncture. The length of the needle used for venipuncture usually depends on the depth of the vein selected and user preference. Multisample needles are available in lengths of 1 to 11⁄2 inches. Syringe needles come in a wide variety of lengths; however, needles 1 to 11⁄2 inches long are commonly used for venipuncture. A 1-inch needle can be much less intimidating to the patient. Butterfly needles are usually 1⁄2 to 3⁄4 inch long. Most manufacturers color-code needles for easier identification, but beware: Color codes are not universal and may vary by manufacturer.
TOOL BOX
FI E L D S M A R T S Patients often request that you use the smallest needle possible to draw their blood. However, smaller needles—especially if used with larger tubes—compromise the integrity of the blood sample and should not be used unless absolutely necessary.
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TABLE 26-1 Common Needle Gauges for Venipuncture GAUGE
TYPE
APPLICATION
20
Multisample or Hypodermic
For collection using large-volume vacuum tubes or large-volume syringes Used for patients with normal-sized veins
21
Multisample or Hypodermic
Standard gauge used for routine venipuncture for patients with normal-sized veins Gauge used for syringe blood culture collection
22
Multisample or Hypodermic
Gauge used for syringe draws on difficult veins Used for older children and adults with small veins
23
Butterfly
Gauge used for infants and children Used for difficult hand veins of adults
25
Butterfly
Gauge used for premature infants and neonates
Syringes The syringe method is used to obtain blood from patients with fragile or thin veins that tend to collapse when using the vacuum tube method. Pediatric or geriatric patients are likely to have these types of veins. Syringes used to perform venipuncture are disposable, made of plastic, and vary in size. The syringe has two main parts: the barrel, with graduated markings in mL or cc, and the plunger, which fits tightly inside the barrel (Figure 26-7). The range of syringe volumes most commonly used for blood collection is 2 to 10 mL. The size of the syringe selected for use is determined by the amount of blood required for collection and the size and con-
FIGURE 26-7 A syringe used for blood draws
dition of the patient’s veins. One disadvantage of the syringe method is that the capacity of the syringe limits the amount of blood that can be collected with one venipuncture. Another disadvantage of the syringe method is that the blood must be transferred from the syringe to evacuated tubes, which requires extra time. Safety transfer devices, such as the one in Figure 26-8, are now available for safer transfer.
VACUUM TUBE SYSTEM The most common method of collecting a blood sample is by using the evacuated or vacuum tube method. This method facilitates the collection of numerous
FIGURE 26-8 An example of a safety transfer device used to transfer blood from the syringe to the collection tubes
COLLECTING THE BLOOD SAMPLE
TOOL BOX
Vein puncturing end
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Tube puncturing end
F IEL D S M A R T S When using a transfer device, immediately remove the external needle. To transfer blood from the syringe to the tubes, push each tube up into the sheathed needle of the transfer device. Invert each tube as you remove it from the transfer device prior to filling a new tube. Once the tubes are done filling, carefully place the transfer device and syringe into the sharps container as one unit.
tubes of blood with one stick. The vacuum tube system also has the advantage of being a closed system. The blood flows from the patient through the needle and into a closed collection tube. This closed system greatly diminishes the risk of exposure to blood for the health care worker. Three main components comprise the vacuum tube system. A specially-designed needle attaches to a disposable plastic holder/adapter that holds the vacuum tubes and various types of evacuated tubes. Figure 26-9 shows an example of the components used in the vacuum tube method of venipuncture.
Multisample Needles Special needles are used with the vacuum tube system to allow multiple tubes of blood to be collected with a single venipuncture. The multisample needle consists of a double needle with a bevel on each end and a threaded hub near the center (Figure 26-10).
FIGURE 26-9 The components of a vacuum tube collection system
Bevel
Shaft
Hub
Rubber sleeve covering needle
FIGURE 26-10 The parts of a multisample needle
The threaded hub of the needle screws into the plastic tube holder. When properly assembled, the longest portion of the needle is exposed and used to puncture the patient’s vein, while the shortest portion fits inside the tube holder and punctures the rubber stopper on the vacuum tube. The portion of the needle that punctures the rubber stopper of the tube is covered with a rubber sleeve. When the tube is pushed onto the needle, the sleeve retracts and exposes the point of the needle, allowing the blood to flow into the tube. When the tube is removed, the sleeve moves back over the needle, stopping the flow of blood. The sleeve prevents leakage of blood both when changing tubes and when the tube is removed prior to withdrawing the needle from the vein. Multisample needles are manufactured with safety features to be used with a traditional tube holder. Singlesample needles without the rubber sleeve are also available when only one tube of blood is needed.
Holders and Adapters A plastic holder or adapter is a cylinder with a small opening at one end where the needle screws into place and a large opening at the opposite end that holds the vacuum tube. Holders are available in an adult size (for regular tubes) and a pediatric size (for small tubes). The large end of the holder is equipped with extensions known as flanges, which aid insertion and removal of the blood collection tubes. Safety holders, such as the ones in Figure 26-11, are either equipped with sleeves that slide over the needle after use, or with covers that snap closed over the contaminated needle. These safety features protect the medical assistant from accidental needlesticks until the equipment can be properly discarded.
Vacuum Tubes Blood collection tubes used with the vacuum tube method are designed to automatically withdraw a precise, premeasured volume of blood. During the manufacturing process, a vacuum is created inside the tube
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FIGURE 26-11 Examples of tube holders with safety devices that cover the needle after use
and is released when the stopper is punctured. The release of the vacuum causes the blood to flow into the tube. When the appropriate volume has been collected, the flow stops and the tube is removed. Collection tubes are available in different sizes and volumes (2 to 15 mL). The size of the tube selected depends on several factors, including the volume of blood required for the test, the size of the needle, the condition of the patient’s veins, and the age of the patient.
Vacuum tubes are available in both glass and plastic. Glass tubes are sometimes coated with silicon on the inside to create a smooth surface, which prevents red blood cell destruction. Vacuum tubes may contain special additives that perform different functions. These are discussed in more depth below. Vacuum tubes that contain additives must be filled to capacity. An underfilled tube can create an incorrect ratio of blood to additive, resulting in inaccurate test results due to dilution of the specimen. Vacuum tubes come with special tube stoppers made of either rubber or plastic. During the blood draw procedure, the needle pierces the stopper, delivering the blood into the tube from the vein. The stopper is removed once full to retrieve the specimen for testing. Benton Dickinson manufactures both conventional rubber stoppers and plastic closures referred to as Hemogard™ Closures. These special safety closures are designed to protect personnel by preventing the specimen from splattering when the closure is removed. Both types of stoppers are color-coded, indicating which type of anticoagulant or additive is contained in each tube. Tube stopper colors may vary by manufacturer and depend on whether the stopper is made of rubber or plastic. Table 26-2 lists the different tube top colors, the additive contained in each, and the types of testing requiring each of the additives.
The latest safety regulations prohibit the removal of needles from used blood tube holders. These regulations are designed to reduce the danger and number of needlesticks for health care workers and any others who may come in contact with medical sharps. The following information is a summary of the latest regulations: ❖ If a multisample needle does not have a safety feature to shield the needle after use, the needle must be used with a tube holder that does have a safety feature. ❖ Removal of contaminated needles is prohibited. ❖ Reuse of a blood tube holder is prohibited. ❖ Both the holder and the needle must be properly disposed of as a unit after use.
❖ Multisample needles are double-ended needle devices and removal exposes employees to an additional risk of needlestick by a contaminated needle. Removal can result in a needlestick from either end. Improper disposal of contaminated needles and devices can affect people other than the user. Personnel that may come in contact with contaminated sharps include housekeepers, maintenance personnel, and personnel that remove biohazardous wastes. These individuals must also be protected from accidental needlestick injuries. As a site inspector, I will be checking to make certain that your facility is in compliance with the standards.
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SITE C H EC K
COLLECTING THE BLOOD SAMPLE
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TABLE 26-2 Common Vacuum Tube Color Guide HEMOGARD CLOSURE
RUBBER STOPPER
ADDITIVE FUNCTION
LABORATORY USE
EDTA (ethylenediaminetetraacetic acid)
Binds calcium to prevent clotting
Hematology testing: CBC, differential, and ESR
No additive
Promotes blood clot formation
Serum testing: hormone studies, organ panels, medication levels, and HIV testing
Clot activator and gel for serum separation
Serum separation; allows technician to pour off serum
Serum testing, same as for the red top
Potassium oxalate and sodium fluoride
Binds calcium and stabilizes glucose
Glucose testing and alcohol levels
Sodium citrate
Binds calcium to prevent clotting
Coagulation studies: PT, PTT, and INR
Sodium heparin
Inhibits formation of thrombin and prevents clotting
Plasma studies for trace elements
Lithium heparin and gel for plasma separation
Heparin prevents the release of potassium by platelets during clotting and the gel separates the plasma from the red cells.
STAT chemistry plasma studies: electrolytes, arterial blood gases, etc.
Lithium or sodium heparin
Inhibits formation of thrombin and prevents clotting
Chemistry plasma studies: electrolytes, arterial blood gases, etc.
Sodium polyanetholesulfonate (SPS)
Binds calcium to prevent clotting and inhibits bacterial growth
Blood or body fluid cultures
Thrombin activator
Results in faster clot formation
STAT serum chemistry testing
ADDITIVE
*Please note: Each tube containing an additive of any kind must be inverted a specified number of times immediately following blood collection. Refer to the manufacturer’s directions for the correct number of inversions.
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FI E L D S M A R T S Manufacturers guarantee the tube vacuum and the stability of the additive until the expiration date shown on the tube. Never use a tube that has expired for patient samples. Laboratories will not accept specimens drawn in expired tubes.
FIGURE 26-12 An SST tube containing thixotropic gel and a plain red top tube
An anticoagulant added to a collection tube prevents the blood from clotting. Many types of anticoagulants are available. The most common types used include EDTA, heparin, oxalates, and citrates. The choice depends on which type of laboratory testing is being preformed. Additives inside the vacuum tube can be used to preserve certain blood components until testing can be performed. Some additives are used to accelerate specimen processing for faster testing. Some tubes, used to collect serum (the liquid portion of clotted blood) samples, are available with a clot activator that helps the clotting process to begin more quickly. Thrombin is a type of clot activator added to speed the clotting process for STAT test results. Another additive found in serum tubes is a gel-like substance, thixotropic separator gel, which forms a barrier between the cells and serum upon centrifugation (Figure 26-12). When centrifuged, the gel becomes liquid and moves up the sides of the tube to form a solid plug between the cells and serum. Once
the plug is in place, the serum can easily be poured off into another tube (Figure 26-13). This type of tube is referred to as an SST/serum separator tube. Some vacuum tubes do not contain an additive; blood collected in a nonadditive tube takes approximately 20 to 30 minutes to clot. Once the blood has clotted, the specimen must be centrifuged to separate the serum from the clotted blood. The serum is then removed by pipette and transferred to another tube to be sent to the lab for testing. Figure 26-14 shows a specimen in a nonadditive tube after centrifugation. The serum must be carefully removed before transport to prevent remixing of cells and serum.
WINGED INFUSION (BUTTERFLY) SYSTEM The winged infusion or butterfly set is used to collect blood from small or difficult veins. Smaller veins are commonly found in pediatric and geriatric patients and in the hands. The set includes a 23 gauge, 1⁄2- to 3⁄4-inch needle connected to a 5- to 12-inch length of
FIGURE 26-13 Changes that occur in the SST tube during the centrifugation process Serum or Plasma Blood
Serum or Plasma
Cells Gel Gel
Cells
Gel
Before Centrifugation
Serum or Plasma
During Centrifugation
Plug Formation
Gel Cells
After Centrifugation
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FI E L D S M A R T S Tube selection is not just about obtaining the correct color; it is also about matching up the right tube with the right needle. Choosing the correct tube size is very important to preserve the integrity of the specimen. When using a larger tube, a larger needle should be used. This is because a larger tube has a greater vacuum; if combined with a smaller needle, cells are forced through the lumen of the needle at a much greater force than what the lumen can handle. This practice causes the cells to be destroyed as they pass through the lumen, resulting in hemolysis (destruction/ rupture of blood cells).
together between the thumb and index finger, the medical assistant can enter the smaller vein at a lower angle. FIGURE 26-14 The medical assistant removes the serum from a plain red-topped tube using a pipette.
plastic tubing. At the end of the tubing is either a hub that attaches to a syringe or a needle that is covered by a rubber sleeve that attaches to a vacuum tube holder (Figure 26-15). The needle has plastic projections attached to it that resemble butterfly wings. By grasping the wings
FIGURE 26-15 Two butterfly needles: one that attaches to a vacuum tube adapter and one that attaches to a syringe
BLOOD COLLECTION TRAY Venipuncture equipment may be located in a special blood drawing area or stored in a blood collection tray, which can be moved from room to room. Trays can vary in design, but because they are used to transport blood specimens, OSHA requires the tray to be red in color or to have the biohazard symbol prominently displayed on the outside of the tray (Figure 26-16). The type of equipment stocked in each tray will depend on the type of specimen that is to be collected. General items contained in most trays include the following: ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖
Antiseptic wipes Sterile gauze/cotton balls Bandages/tape Multisample and single-use needles, hypodermic needles for use with a syringe, and winged infusion needles Syringes and vacuum tube adapters of various sizes Transfer devices Evacuated tubes of different sizes and types Tourniquets Sharps container
Always replace used equipment and dispose of contaminated wastes from the blood collection tray after each use.
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FIGURE 26-16 Examples of fully stocked blood collection trays
PERFORMING THE VENIPUNCTURE Venipuncture is the process of puncturing a vein with a needle to obtain a blood specimen and is the most common method used to collect blood. It is a specialized procedure that requires numerous steps that must be precisely performed. Table 26-3 lists the general steps to be followed when performing a venipuncture by any of the three methods previously mentioned. Specific procedural steps for each method can be found in Procedures 26-1, 26-2, and 26-3.
Assembling Equipment and Supplies
TABLE 26-3 General Steps for Performing a Venipuncture Check the provider’s orders for testing. Assemble and inspect the equipment. Label the tubes. Identify the patient using two identifiers, identify yourself, and explain the procedure. Verify restrictions (such as fasting). Wash hands and apply the appropriate PPE. (For the best protection, the medical assistant should wear a mask, goggles, waterproof lab coat, apron or gown, and gloves.)
It is important to assemble all necessary equipment before beginning the venipuncture. All supplies should be within easy reach to avoid crossing over the patient’s arm during the procedure. Several spare tubes should be available in case a tube has a defective vacuum and will not fill completely. Table 26-4 lists the necessary equipment for performing the venipuncture.
Properly position the patient.
Identifying the Patient
Use a 10% bleach solution for cleaning spills and the work area.
Proper identification of the patient is vital to ascertain that the testing is performed on the correct patient. Occasionally, when the medical assistant calls a patient’s name, an anxious or distracted patient may answer in error. Some names sound alike and it is even possible to have two patients with the same name. Ask
Perform venipuncture. Follow specimen handling instructions. Check the site and apply pressure dressing. Properly dispose of sharps and contaminated equipment according to OSHA guidelines.
Remove gloves and wash hands. Log the specimen and process the paperwork. Document the procedure in the patient’s chart.
COLLECTING THE BLOOD SAMPLE
TABLE 26-4 Venipuncture Equipment Gloves/PPE Tourniquet Cotton balls or sterile gauze Alcohol wipes Needle Needle/tube holder or syringe Tubes, including extras Bandage
the patient to give a full name and to provide a second identifier, such as date of birth or the last four digits of the social security number. This will help to avoid a mixup.
Positioning the Patient
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E M R A P P L I C AT I O N Check the personal notes section of the patient’s EMR prior to escorting the patient back to the examination room. A variety of information may be displayed in this section, such as the phonetic spelling of the patient’s name, special events coming up in the patient’s life, or useful tips that can assist personnel while working with the patient. Examples include: Patient is deaf on left side; Patient had a mastectomy on the right side—only take blood pressures and perform phlebotomy in the left arm; Patient has a history of syncope during or following blood draws, have patient lay down for all invasive procedures. Knowing this information ahead of time may help prevent complications from occurring because a patient forgets to share the details or is embarrassed about sharing the information.
Proper patient positioning will help to ensure a successful venipuncture. Patients should be lying down or seated during blood collection. Never draw blood from a patient who is standing or seated on a high stool.
What you should know prior to the procedure: If a patient’s medical history is unfamiliar to you, there are specific questions that you should ask prior to performing phlebotomy. They include the following: ❖ Do you have any latex allergies? (If yes, wear nonlatex gloves during the procedure.) ❖ Have you ever had a reaction to an adhesive bandage? (If yes, apply a piece of cotton or gauze to the site following the venipuncture, and secure it with a piece of paper tape.) ❖ Have you had a mastectomy? (If yes, perform the phlebotomy on the opposite side that the mastectomy was performed. If the patient has had a double mastectomy, ask the provider how to proceed.) ❖ Are you taking any blood thinners, or are you on aspirin therapy? (If yes, be especially careful about moving the needle
around. Injury to the vessels may cause prolonged bleeding under the skin. Apply pressure for a minimum of two to five minutes following the blood draw and apply a pressure bandage.) ❖ Do you have a port or shunt? (If yes, the sample must be drawn from the opposite arm.) ❖ Do you have a history of fainting associated with having your blood drawn? (If yes, position the patient in a supine or semiFowler’s position.) If at all possible, review the patient’s history prior to escorting the patient back to the room. The patient will have more confidence in you if you already know the information because you reviewed the chart first. Any new information gained during questioning should be placed in the patient’s health record.
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F IELD SM A RTS
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Positioning of the patient will depend on the vein selected. Blood is usually drawn from one of several veins located in the antecubital space of the arm, which is the area located on the inside of the arm at the bend of the elbow. Patients are usually seated for blood draws unless there is a risk of the patient fainting. The arm should be supported on the arm of a chair, the exam table, or a table/countertop and should extend downward in a straight line. By placing the arm in a downward position, the veins will enlarge and become more prominent. The downward position also helps the blood tubes to fill from the bottom up and helps prevent reflux. While reflux is uncommon, it can occur if blood flows back into the patient’s vein from the vacuum tube. If the tube contains an additive, especially EDTA, the patient could have an adverse reaction. The arm should be straight, not bent, which makes the vein easier to locate. Placing the fist of the other hand under the elbow will help with straightening the arm. Some patients become quite nervous prior to having their blood drawn and will find it difficult to remain still if seated. Extremely anxious patients and those who have a history of syncope (fainting) should be placed on the exam table in a supine or semi-Fowler’s position. A pillow with a disposable waterproof covering may be placed under the patient’s arm for support and proper positioning.
Selecting the Site An examination of the skin should be performed before selecting the actual vein. Avoid areas with extensive
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CR ITI C A L TH I N K I N G C H AL LEN G E A new patient appears to be quite apprehensive prior to having her blood drawn. You ask all of the appropriate screening questions and the patient denies any history of problems with blood draws in the past. You place the tourniquet on the patient’s arm, and notice the color leaving the patient’s face and perspiration pouring off her forehead. You ask the patient if she is okay, and she states that she is fine but just wants to get the procedure over with. 1. What would be the appropriate step to take at this point in the procedure? Explain the rationale for your answer.
scarring or burns when selecting a site. Blood should not be collected from an edematous region (area that is swollen), an area where a hematoma (blood clot) is located, or an area on the skin that appears infected. Venipunctures should not be performed on the same side where a mastectomy was performed. This may cause lymphostatis, a condition that obstructs the normal flow of lymph due to the removal of lymph nodes from the axillary region. The most common site for venipuncture is the antecubital space of the arm. This area is located where the upper arm and the forearm meet. Three prominent veins are located in this area: the median cubital, cephalic, and basilic veins (Figure 26-17). The median cubital is usually the vein of choice. It is a large vein located in the middle of the antecubital area; it is close to the surface and easily accessible. If the median cubital vein is not suitable, the basilic vein (located toward the inner portion of the arm) or the cephalic vein (located toward the outer portion of the arm) may be used. The first step in selecting a vein is to apply a tourniquet 3 to 4 inches above the venipuncture site. It should be tight enough to slow the flow of blood in the veins but not so tight that it stops the blood flow in the arteries. By slowing the flow, the blood will pool in the veins, causing them to dilate (enlarge) and making them easier to palpate. The tourniquet should feel tight but not painful. Never leave the tourniquet on the arm longer than one minute. This can cause a condition known as hemoconcentration, which is caused by pooling of blood; this can increase the concentration of certain blood components and result in inaccurate test results. Once the tourniquet is properly applied, the medical assistant should use the index finger to palpate the
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FI E L D S M A R T S Veins are not always visible to the eye and must be located by palpating areas where veins are generally located. Learn to use landmarks on the skin to locate the vein, such as a freckle, mole, scar, or crease in the skin. Also know that veins do not always run in a straight line. Run your finger over the vein in both directions to determine the vein’s position. Insert the needle so that it is positioned in direct alignment with the vein.
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Basilic Cephalic
Brachial Artery
Median Cubital
Median
Radial Artery
Ulnar Artery
FIGURE 26-17
(a)
(b)
vein by firmly pressing and releasing the vein several times. The thumb should not be used for palpating veins. A vein will feel similar to a spongy rubber tube. If the vein is difficult to palpate, it can be made more prominent by tapping the area with the index and middle finger, which will cause the vein to dilate. Rubbing the arm from wrist to elbow to force the blood into the vein or covering the area with a warm compress can also increase the blood flow and make the vein easier to feel. Veins that feel hardened or scarred should not be selected due to inadequate blood flow. If a pulse is felt in the vessel, it could be the brachial artery, which is also located in the antecubital space. Puncturing an artery should be avoided. It is painful and can produce inaccurate test results. When trying to locate a proper vein for venipuncture, remember that tendons and nerves also run the length of the arm and can be quite painful if punctured. Tendons located near the surface will feel hard and cord-like and should not be mistaken for a vein. Nerves cannot be seen or felt, but can usually be avoided by not performing deep or probing venipunctures. If the patient experiences unusual pain during the venipuncture, the process should be stopped immediately and another site selected.
(a) Surface veins used for venipuncture (b) Major arteries of the arm that should be avoided during a venipuncture
Both arms should be inspected for a suitable site before proceeding. If neither arm appears appropriate, alternative sites are located on the back of the hand, the back of the wrist, the ankle, or the foot. Veins on the back of hand and the back of the wrist are small and tend to roll easily, so a collection system with a small gauge needle should be used. Veins of the ankle or foot should only be used with the provider’s permission.
SPECIMEN COLLECTION BY THE SYRINGE METHOD Venipuncture by the syringe method is commonly performed for difficult draws, such as those performed on patients with fragile or weak veins. By using a syringe, the blood may be drawn more slowly than with the vacuum tube method and can prevent the vein from collapsing. Blood collection tubes must be filled in a specific order, according to the order of draw established by the National Committee of Clinical Laboratory Standards (NCCLS), now referred to as the Clinical and Lab Standards Institute (CLSI). The purpose of the order is to prevent possible cross-contamination from the collection tube additives, which could result in
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erroneous test results. The order of draw has been revised several times; the CLSI currently recommends the same order of draw for both the syringe method and the vacuum tube method. Table 26-5 lists the order of draw. When blood is drawn into a syringe, microclot formation can begin quickly while the blood is still in the syringe. For this reason, some facilities still prefer to use a separate order of draw for syringe collection to prevent microclots from forming in tubes with additives. These small clots can become lodged in automated laboratory equipment and can also affect test results. Refer to Procedure 26-1 for complete step-bystep instructions on collecting a blood sample by the syringe method.
SPECIMEN COLLECTION BY THE VACUUM TUBE METHOD The vacuum tube method is usually the method of choice for routine blood specimen collection. This method has several advantages over the syringe method. Multiple tubes of blood for a variety of tests can easily be collected with one needlestick. Blood is drawn directly into collection tubes containing an additive, and can be mixed immediately to prevent microclot formation. The risk of accidental needlestick is also reduced because the blood does not need to be transferred from the syringe to a collection tube. Procedure 26-2 supplies the necessary information and steps for collecting a blood sample by the vacuum tube method.
SPECIMEN COLLECTION BY THE BUTTERFLY METHOD The butterfly or winged infusion collection system has the advantages of both the vacuum tube system and the syringe method. Two types of winged infusion systems are available: one for use with a syringe and one for use with the vacuum tube system. This system was designed to be used for veins that are difficult to puncture with a standard size needle. The winged needle is easy to slide into the surface veins of the hand, wrist, or foot. The butterfly can also be used for very small veins in the antecubital area, but should not be used routinely for this purpose. Procedure 26-3 lists the steps required to perform a venipuncture using a butterfly or winged infusion set.
PATIENT RESPONSE AND COMPLICATIONS Many patients are fearful of having their blood drawn. Complications may arise as a result of venipuncture such as a hematoma, prolonged bleeding from the puncture site, infection, nerve damage, reflux, vein damage, and collapsed veins. The medical assistant must be prepared to deal with different situations and know how to correctly respond in the event the patient suffers an adverse reaction or complication. Table 26-6 lists some possible reactions the patient may experience and how the medical assistant can best prevent or handle the situation.
TABLE 26-5 CLSI Recommended Order of Draw ORDER OF DRAW
TUBE COLOR
ADDITIVE
Sterile culture bottles or tubes
Yellow
Sodium polyanetholesulfonate (SPS)
Coagulation tubes
Light blue
Sodium citrate
Serum tubes with or without a clot activator and with or without separator gel
Red Gold Speckled
No additive/plain Clot activator and gel Gel separator for tubes with gel
Heparin tubes with or without gel
Green
Sodium heparin Lithium heparin Gel separator for tubes with gel
EDTA tubes
Lavender
Ethylenediaminetetraacetic acid (EDTA)
Glycolytic inhibitor
Gray
Sodium fluoride Potassium oxalate
Source: NCCLS (Now CLSI), “Order of Draw,” H3-A5, Vol. 23, No. 32, 8.10.2.
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TABLE 26-6 Venipuncture Adverse Reaction Responses PATIENT REACTION
MEDICAL ASSISTANT’S RESPONSE
Pain during venipuncture
Gently reposition the needle. If pain persists, remove the needle and stop venipuncture immediately.
Nausea
Instruct the patient to breathe slowly and deeply through the mouth. Apply cold damp compress to the patient’s forehead. Give the patient an emesis basin.
Fainting/syncope
Patients with a history of syncope should lie down while having their blood drawn. If the patient feels faint or does faint while lying down, remove the tourniquet and needle and elevate the patient’s feet. If the patient feels faint while seated, immediately remove the tourniquet and needle and have the patient lower the head between the knees if conscious. If unconscious, call for help and gently lower the patient to the floor. Elevate the patient’s feet. Whether the patient is seated or lying down: Once the patient is properly positioned, apply cool compresses to the forehead and the back of the neck, manage the puncture site, and get directions from the provider.
Seizures/convulsions
Remove the tourniquet and needle immediately. Apply pressure to the venipuncture site without restricting the patient’s arm movement. Lower the patient to the floor and move objects out of the way to prevent injury to the patient. Notify the provider immediately.
Hematoma
Stop the venipuncture immediately. Apply firm pressure to the site for five minutes. Apply an ice pack to the site. See Table 26-7 for hematoma prevention tips.
Prolonged bleeding
Apply pressure for a minimum of five minutes. If bleeding continues, apply pressure until bleeding stops. Notify the provider.
Nerve damage
Do not probe deeply with the needle, especially if there is no blood flow or if the patient complains of pain. Gently reposition the needle and if no blood flow appears, stop the venipuncture and choose an alternative site.
Infection
Infection is rare, but can occur. Following aseptic guidelines will help prevent infections from occurring.
Reflux
The patient’s arm should be in a downward position. Do not allow the tube contents to move back and forth while the needle is in the patient’s vein.
Vein damage
Avoid repeated venipunctures in the same vein. Do not probe blindly or use improper technique when repositioning the needle.
Collapsed vein
If the vein disappears or the blood flow suddenly stops, try another tube or stop the venipuncture.
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CR ITI C A L TH I N K I N G C H AL LEN G E Three patients are waiting to have their blood drawn. After reviewing their histories you see that Patient A has a history of veins that collapse easily, Patient B can only be stuck in the hand, and Patient C doesn’t have any history of problems from blood draws. 1. Which collection setup would you most likely use for each patient?
TABLE 26-7 Hematoma Prevention Tips Use smaller needles for small or fragile veins. Consider using a syringe for these types of veins. Avoid going through the vein, partially penetrating a vein, or excessive movement while the needle is in the vein. The bevel of the needle should be completely covered. Use smaller size tubes when using smaller needle gauges. Do not probe blindly. Remove the tourniquet prior to withdrawing the needle.
Hematoma is one of the most common complications resulting from a venipuncture. It is a swelling or bruising resulting from an accumulation of blood at the puncture site. This accumulation of blood is usually caused by leakage from the vessel that was punctured. Table 26-7 lists some hematoma prevention tips.
Have the patient apply direct pressure for a minimum of two to five minutes following the draw and instruct the patient not to lift anything heavy with the affected arm for several hours following the draw.
THE FAILED VENIPUNCTURE
CRITERIA FOR SPECIMEN REJECTION
There are numerous reasons for a failed venipuncture. By being aware of possible errors and taking steps to correct them, the medical assistant can usually successfully collect blood during the first attempt. Table 26-8 lists potential problems and the steps necessary to correct them.
When collecting a blood specimen, one of the medical assistant’s first responsibilities is to provide the laboratory with an adequate specimen that has been properly collected and processed. Poor specimen quality can affect test results and in turn delay treatment. Specimens can be rejected for a variety of reasons, such
TABLE 26-8 Causes of Failed Venipuncture POSSIBLE CAUSES Needle Position: • bevel against wall of vein • bevel partially inserted • needle too deep • needle beside vein
STEPS TO CORRECT Slightly rotate the bevel. Slowly advance the needle until blood begins to flow. Withdraw the needle slightly. Remove the tube from the needle, withdraw the needle until the bevel is just under the skin, anchor the vein and redirect the needle into the vein. Use a new tube after redirecting the needle.
Collapsed vein
The tourniquet may be too tight—remove it. Pressure from the vacuum in the tube can collapse a vein, so a smaller volume tube may be necessary.
Tube vacuum insufficient
Try another tube first. Do not use tubes that have expired or that have been dropped.
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F IEL D S M A R T S Most practices have what is referred to as a twostick rule: Never attempt more than two sticks per patient. It is hard on the patient, hard on you, and makes the practice look bad. Ask someone with more experience to take over. If possible, watch to see if that individual has a different technique. Don’t feel bad if you miss some patients; even the most experienced phlebotomists miss from time to time.
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by a short draw. A sufficient amount of specimen must be available for testing. If there is an insufficient amount, the specimen will be referred to as quantity not sufficient (QNS) and must be redrawn.
Incorrect Collection Time Specimens for some laboratory tests, such as some glucose tests and therapeutic drug monitoring, must be collected at specific times or the lab will reject the specimen. If a specimen is collected at the wrong time, it must be noted on the requisition form and the laboratory will make the determination if it is adequate for testing.
Incorrect Specimen Handling as improper labeling, using incorrect tubes, incorrect collection time, incorrect specimen handling, or sending a hemolyzed or lipemic specimen. If a specimen is rejected or inaccurate test results are suspected, the specimen will need to be redrawn.
Improper Labeling of Specimen Tubes A specimen can be rejected for reasons as simple as an error in labeling. Each specimen must have a label that contains the following information: ❖ Patient’s full name and identification number, if applicable ❖ Date and time of collection ❖ Initials of person collecting the specimen ❖ Tests ordered (optional)
Use of Incorrect Specimen Tubes Specimens must be collected in the correct tube containing the proper additive. An incorrect additive can adversely affect test results. For example, if plasma is required for testing, the specimen must come from a tube with an anticoagulant. If serum is required, the specimen must come from a clot tube. Because serum and plasma look the same to the naked eye, proper tube choice is critical. Always check the lab manual for collection requirements. Vacuum tubes must be filled to the proper capacity in order to provide a good quality specimen for testing. If the tube is only partially filled, known as a short draw, the ratio of additive to blood will be improper and can be the source of inaccurate test results. Improperly filled tubes used for coagulation studies (light blue top) are rejected by most laboratories due to the increased amount of additive, which dilutes the specimen and produces erroneous results. A partially filled plain tube can still be used for testing, as serum is not affected
Some specimens must be collected and stored in the proper environment until the test can be performed. It is important for the medical assistant to check the lab manual prior to collecting a blood specimen for special collection and handling instructions. Certain substances such as bilirubin are sensitive to light and must be protected by wrapping the tube in foil following collection or pouring the substance into a special amber-colored tube. Another component is temperature sensitivity. Some specimens must be frozen or kept cold while others must be kept at room temperature until testing can be performed.
Hemolyzed and Lipemic Specimens Hemolysis occurs when the red blood cells rupture and release hemoglobin into the liquid portion of the specimen. The serum or plasma may appear pink (slight hemolysis) to red (gross hemolysis) in color. Hemolyzed specimens will affect the accuracy of certain laboratory tests, such as the complete blood count (CBC), potassium levels, and certain enzyme levels. Hemolysis is most commonly caused by errors in the collection process, but can be caused from certain abnormal patient conditions, such as liver disease and hemolytic anemia. The most common collection errors resulting in hemolysis include the following: ❖ Collecting a specimen from a vein with a hematoma ❖ Using a needle gauge that is too small for venipuncture ❖ Using a large vacuum tube with the butterfly system or a smaller needle ❖ Vigorous mixing of additive tubes ❖ Blood frothing caused by incorrect fitting of the needle on the syringe ❖ Pulling back too quickly on the plunger during a syringe draw
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A lipemic specimen is one that has a cloudy or milky appearance. Lipemia can be caused by ingesting fatty foods prior to specimen collection or by certain physiological conditions. Since lipemia can appear anywhere from 1 to 10 hours after ingestion of fats, a 12-hour fast is required for accurate cholesterol and triglyceride levels. Because a lipemic specimen is cloudy, it may interfere with certain chemistry tests. Figure 26-18 illustrates the appearance of a hemolyzed and lipemic specimen.
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P A T I E N T P E R S P E CT IV E I can hardly get around because of my arthritis, and it is so hard for me to get to the office to see my physician. I came in two days ago and had my blood drawn and believe me, it wasn’t easy to get blood from either of my arms. The medical assistant had a difficult time. My arm is still so sore, and now I get a phone call telling me I have to come in and have my blood drawn again. The lab said they didn’t have enough blood to complete the test. After this testing is completed, I am going to find a new physician. If a physician can’t hire competent employees, I do not want that person as my physician.
THE CAPILLARY PUNCTURE The capillary puncture, also known as a skin or dermal puncture, is used when a venipuncture is not the preferred method of specimen collection. It is the method of choice for infants and children under the age of two due to their extremely small veins and low blood volume. The capillary puncture is also used for certain adults whose veins are fragile and weak due to age or illness. Many test methodologies have been developed that require only micro amounts of blood, which can be easily obtained by capillary puncture. Capillary samples can be tested at the location of collection for point-of-care testing (POCT). POCT produces immediate results and eliminates the need for specimen processing and transport. Examples of POCT
FIGURE 26-18 An example of the appearance of both a hemolyzed specimen (left) and a lipemic specimen (right)
tests include hemoglobin and hematocrit, blood glucose, cholesterol, and coagulation studies. If a specimen is collected by capillary puncture and sent to an outside laboratory for testing, the collection method must be noted on the specimen container and on the requisition form because certain tests such as glucose, calcium, and potassium will have different results than those of a venous blood sample. Blood collected by the capillary method is primarily made up of arterial blood, which is found in greater amounts in the capillaries than venous blood. The capillary specimen is also a mixture of interstitial fluid found between the cells and tissues of the body and the blood from arterioles, venules, and capillaries.
Equipment The equipment used to perform the capillary puncture is very similar to that used to perform a venipuncture with a few exceptions. The following is a list of the necessary supplies and equipment needed to perform this procedure: ❖ ❖ ❖ ❖ ❖ ❖
Alcohol wipes Cotton balls Gloves Adhesive bandage Lancets Micro collection containers
Some of the lancets are self-contained, such as those in Figure 26-19, and have the plunger device already attached, while others must be used with a springloaded device such as the one shown in Figure 26-20.
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FI E L D S M A R T S Specially designed lancets should be used for infant heel punctures. These lancets only puncture to a predetermined depth to eliminate the possibility of puncturing the heel bone. It is important not to puncture the bone as this could result in a serious infection known as osteomyelitis. FIGURE 26-19 Examples of Microtainer Genie brand lancets that come in different sizes for different uses. They are colorcoded according to their use.
safest area to reduce the possibility of striking the heel bone during the puncture. When selecting a site, it is important to choose an area that is warm and pink, and not edematous, cyanotic, or cold. Figure 26-21a illustrates the most common sites used for capillary blood collection.
Preparing the Site
FIGURE 26-20 A puncture device used with another type of lancet
Common Sites for Collection The most common sites for capillary collection in adults and children are the tips of the middle (great) or ring finger. Using the earlobe is no longer recommended. For specimen collection from an infant, the medial or lateral plantar surface of the heel is used, as this is the area that has the most soft tissue and is the
(a)
Collecting the Specimen The skin puncture is performed on the tip of the finger, off to the side (Figure 26-21b). The first drop of blood is wiped away before collection of the specimen because it is diluted with tissue fluid, which can dilute the levels of the components being tested. The site
FIGURE 26-21 (a) Com-
(b) Correct
Infant’s heel
A warm puncture site is one that has adequate blood flow for capillary collection. If the skin is cool, circulation can be increased by warming the site with a warm, moist towel or through gentle massage. The site must be disinfected with 70% isopropyl alcohol and then allowed to air dry or immediately wiped with a clean or sterile piece of cotton or gauze. If alcohol is carried into the puncture site because of inadequate drying time after cleansing, it can cause hemolysis of the specimen as well as discomfort for the patient.
Ring/great finger
Incorrect
mon sites used for capillary puncture; (b) Correct puncture pattern—across the grain of the fingertip, not along the grain
638
❖
CHAPTER 26
may be gently squeezed and released to promote an adequate drop of blood. The collection container should be held below the puncture site and touched to the drop of blood. Refer to Procedure 26-4 for the complete, detailed steps for collecting a capillary sample.
TOOL BOX
FI E L D S M A R T S It is estimated that between 46% and 68% of laboratory errors occur during the pre-analytical phase of blood testing. Take precautions during the collection, handling, and processing of specimens by making certain that you follow all specifications for each phase of the procedure.
Order of Draw The order of draw for capillary collection differs from that of specimens collected by venipuncture. Platelets can accumulate at the puncture site resulting in erroneous test results. The CLSI recommends the following order of draw for capillary punctures: 1. Lavender-topped (EDTA) tubes for hematology studies 2. Other additive tubes such as green-topped (heparin) tubes and serum-separator tubes (gel) 3. Nonadditive tubes (red-topped), which contain no anticoagulants, gels, or clot activators
❖
❖
GENERAL GUIDELINES FOR SPECIMEN HANDLING Because different laboratories employ different testing procedures, it is critical that the medical assistant follow specimen handling guidelines outlined in the laboratory user manual in the medical facility. Errors that affect patient results often occur during collection, processing, storage, and transport of specimens. Specific specimen-handling guidelines will be discussed in Chapters 27, 28, and 29. General guidelines are as follows: ❖ Vacuum tubes containing an additive should be gently inverted immediately following collection to completely mix the additive with the specimen. Each additive requires a specific number of inversions. Vigorous mixing can cause hemolysis.
❖ ❖
Insufficient mixing can cause microclot formation, which will produce erroneous test results. Transport all tubes containing blood with the stopper in the upright position to prevent the tube contents from coming in contact with the stopper, which could contaminate the specimen. According to CLSI and OSHA, specimens other than blood must be transported in leak-proof containers with tight lids and placed in a sealed plastic bag displaying the biohazard symbol. All paperwork should be attached to the outside of the bag. Specimen-handling guidelines for temperature and protection from light must be followed exactly. The CLSI recommends that serum or plasma be separated from the cells within two hours after collection. Some specimens must be separated in a quicker time frame. The laboratory used by each facility will supply specific information on this process.
Some specimens are collected in a primary container, or original container. Following collection and processing, an aliquot, or portion, of the specimen is taken from the primary container for transport to the laboratory.
COLLECTING THE BLOOD SAMPLE
❖
PROCEDURE 26-1 Venipuncture (Syringe Method) Objective: To withdraw a venous blood sample for laboratory testing as requested by the provider. (This method is usually used for fragile or weak veins and those that could collapse when using the vacuum tube method.)
Equipment/Supplies: ❖ ❖ ❖ ❖ ❖ ❖ ❖
Gloves PPE Alcohol wipes Cotton balls Syringe (10 to 20 cc) Syringe needle (21 to 22 g) Transfer device
PROCEDURAL STEPS
❖ ❖ ❖ ❖ ❖
Tourniquet Vacuum tubes Adhesive bandage Sharps container Patient’s chart
RATIONALE
1. Check the provider’s order and complete the laboratory requisition form.
Verification of tests ordered ensures the correct tests are performed.
2. Wash your hands and apply PPE.
The types of PPE worn will vary from office to office; however, wearing a full set of PPE will provide you with the most protection possible.
3. Assemble all the necessary equipment, and loosen the plunger by pulling it all the way back and pushing it all the way in at least one time. Label all tubes.
Loosening the plunger before beginning the blood draw will prevent the plunger from sticking during the procedure. Labeling tubes before the draw eliminates the possibility of error later.
4. Identify the patient using at least two identifiers and identify yourself.
Always clearly identify the patient using two identifiers (for example, name and date of birth) before collecting the blood sample to be sure you are collecting the specimen from the correct person.
5. Explain the procedure.
If the patient is informed about the procedure, the patient will be more relaxed and less fearful.
6. Verify compliance of fasting instructions and other restrictions (for instance, the need to draw blood from one side or another due to a mastectomy or the presence of a shunt).
If the patient is not compliant with certain fasting instructions, the sample will have to be drawn at another time or test results could be adversely affected. Drawing blood from the side on which a patient has had a mastectomy may result in lymphedema.
7. Visually inspect the patient’s skin and veins in both arms. Always ask if the patient has a preference. Patients usually know which veins produce the best results.
Entering edematous tissue, areas with burns, or other inflamed tissue may cause harm to the patient. Checking the veins in both arms will ascertain that you are using the best site possible.
8. Select the potential site and apply the tourniquet 3 to 4 inches above the elbow. The tourniquet should not remain in place longer than one minute.
Applying the tourniquet too close to the puncture site can cause a decrease in the flow of blood, making the blood sample more difficult to obtain. A tourniquet left in place too long can cause hemoconcentration. continues
639
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❖
CHAPTER 26
continued
PROCEDURAL STEPS 9. Palpate the vein using your index finger, moving in an upward and downward direction (Figure 26-22).
RATIONALE Palpating the vein moving in an upward and downward direction helps to inflate the vein and helps to determine its direction.
10. Ask the patient to make a fist and hold.
Making a fist helps to enlarge the vein.
11. Place the fist of the patient’s other hand under the elbow of the arm being used for the blood draw.
This helps to keep the arm straight and steady.
12. Cleanse the site with alcohol using a circular motion (Figure 26-23).
This cleanses the skin of surface bacteria in the puncture area and decreases the risk of infection from the puncture.
13. Allow the area to air dry, or dry wipe the area with a clean/sterile cotton ball or gauze.
Dry wiping the area decreases the waiting time before puncturing and also decreases the chances of carrying alcohol into the puncture site, which could sting.
14. Pull the skin taut to anchor the vein (Figure 26-24).
Anchoring the vein keeps it from rolling.
15. Insert the needle using a 15° to 30° angle and make certain that the bevel is upward. (Figure 26-25).
The needle must be bevel up for easy blood flow.
16. When blood appears in the hub of needle, slowly pull back on the plunger at a steady rate using the opposite hand (Figure 26-26).
Using the other hand to pull back on the plunger eliminates movement of the needle. Slow, steady pressure on the plunger prevents hemolysis.
17. Allow the syringe to fill completely. 18. Instruct the patient to open the hand. 19. Release the tourniquet (Figure 26-27).
The tourniquet should be released before removing the needle from the vein to eliminate blood squirting due to the pressure of the tourniquet.
20. Place a dry cotton ball above the site, withdraw the needle, and ask the patient to apply firm pressure to the site for two to five minutes (Figures 26-28 and 26-29).
Placing a cotton ball above the site keeps the patient from seeing the needle as it is withdrawn. Continuous pressure must be applied to stop the bleeding and prevent hematoma.
21. Push the sheath over the needle and carefully remove it from the syringe. Discard the needle into the sharps container.
Activating the safety device will help to protect you from harm when removing the needle.
22. Carefully transfer the blood from the syringe to vacuum tubes using a safety transfer device.
OSHA regulations require the use of a safety transfer device to reduce the possibility of needlestick injury.
23. Immediately mix each filled tube according to the manufacturer’s instructions.
Mixing the tubes immediately reduces the possibility of microclot formation.
24. Discard used equipment according to OSHA standards.
Proper disposal of contaminated equipment reduces the possibility of accidental exposure to the health care worker.
25. Check the puncture site and apply a pressure bandage.
Always check the site before applying the bandage to be sure that bleeding has subsided.
26. Dismiss the patient.
COLLECTING THE BLOOD SAMPLE
❖
Skin
Median basilic vein
Circular motion Blood vessel
FIGURE 26-22 Palpate the vein and check its direction.
FIGURE 26-23 Cleanse the area with alcohol and either wipe dry or allow to air dry.
FIGURE 26-24 Pull the skin FIGURE 26-25 The correct taut and insert the needle.
route of entry
FIGURE 26-26 Pull slowly
FIGURE 26-27 Release the
FIGURE 26-28 Apply a
on the plunger and withdraw blood.
tourniquet.
cotton ball slightly above the puncture site.
FIGURE 26-29 Instruct the patient to apply firm pressure to the site until bleeding has stopped.
PROCEDURAL STEPS
RATIONALE
27. Clean the work area. 28. Remove gloves and wash your hands. 29. Document the procedure in the patient’s chart and in the lab log.
Include the phlebotomy method, location, tests ordered, types of tubes drawn, and the name of the laboratory where tests were sent.
DOCUMENTATION EXAMPLE:
02-24-XX 10:30 a.m.
Phlebotomy (syringe method), L. antecubital for CBC and ESR per Dr. Leonard. 2 lavender tops sent to ABC Labs. –complications. Abisha Hood, CMA (AAMA)
641
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CHAPTER 26
PROCEDURE 26-2 Venipuncture (Vacuum Tube Method) Objective: To collect multiple tubes of venous blood for testing with one needlestick to the patient.
Equipment/Supplies: ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖
Gloves PPE Tourniquet Alcohol wipes Cotton balls Adhesive bandage Multisample needle (20 to 22 gauge) Vacuum tube holder with needle safety shield
PROCEDURAL STEPS
❖ Vacuum tubes ❖ Sharps container ❖ Patient’s chart
RATIONALE
1. Check the order and complete the laboratory requisition form.
Always verify that tests being drawn are correct according to provider’s orders.
2. Wash your hands and apply PPE. Remember the amount of PPE worn may vary from one facility to the next.
PPE must be worn to protect the individual collecting the sample.
3. Assemble all the necessary equipment and label all tubes.
Assembling all equipment before beginning the procedure helps the procedure to go a lot more smoothly. Labeling tubes before the draw eliminates the possibility of error later.
4. Identify the patient using at least two identifiers. Identify yourself.
Always use two identifiers to be certain that you have the correct patient.
5. Explain the procedure.
If the patient is informed about the procedure, the patient will be more relaxed and less fearful.
6. Verify compliance of fasting instructions and other restrictions (for instance, the need to draw blood from one side or another due to a mastectomy or the presence of a shunt).
If the patient is not compliant with certain fasting instructions, the sample will have to be drawn at another time, or test results could be adversely affected. Drawing blood from the side on which a patient has had a mastectomy may result in lymphedema.
7. Visually inspect the patient’s skin and veins in both arms. Always ask if the patient has a preference. Patients usually know which veins produce the best results.
Going into edematous tissue, areas with burns, or other inflamed tissue may cause harm to the patient. Checking the veins in both arms will ascertain that you are using the best site possible.
8. Apply a tourniquet 3 to 4 inches above the elbow. The tourniquet should not remain in place longer than one minute.
Applying the tourniquet too close to the puncture site can cause a decrease in the flow of blood, making the blood sample more difficult to obtain. Leaving the tourniquet in place too long can cause hemoconcentration.
COLLECTING THE BLOOD SAMPLE
PROCEDURAL STEPS 9. Ask the patient to make a fist and hold.
❖
643
RATIONALE Making a fist helps to enlarge the vein.
10. Place the fist of the patient’s other hand under the elbow of the arm being used for the blood draw.
This helps to keep the arm straight and steady.
11. Palpate the vein and selected final site (Figure 26-30).
Always palpate the vein upward and downward to determine its direction.
12. Cleanse the site with alcohol using a circular motion (Figure 26-31).
This cleanses the skin of surface bacteria in the puncture area and decreases the risk of infection from the puncture.
13. Allow the area to air dry, or dry wipe the area with a clean/sterile cotton ball.
Dry wiping the area decreases the waiting time before puncturing and also decreases the chances of carrying alcohol into the puncture site, which will sting.
14. Pull the skin taut to anchor the vein.
Anchoring the vein keeps it from rolling.
15. Using a 15° to 30° angle, insert the needle with the bevel up (Figure 26-32) and tube label down.
The needle must be bevel up for easy blood flow. The tube label down makes it easier to see the blood flow into the tube.
16. Using the hand that anchored the vein, grasp the flanges of the holder and push the tube until the needle punctures the stopper and blood flows into the tube (Figure 26-33).
Using the other hand to change tubes eliminates movement of the needle in the patient’s arm.
17. Allow the tube to fill to the desired level before changing the tube (Figure 26-33). Withdraw the tube and mix the additive tubes immediately .
Tubes are designed to fill to a predetermined volume. This ensures the correct ratio of blood to additive. Immediate mixing of the additive tubes prevents the formation of microclots.
FIGURE 26-30 Palpate for the vein
FIGURE 26-31 Cleanse the site with
in an up–and-down direction.
alcohol, moving in a circular motion.
FIGURE 26-32 Insert the needle
FIGURE 26-33 With your nondomi-
using a 15° to 30° angle with the bevel up.
nant hand, push the vacuum tube onto the needle, allowing it to completely fill.
continues
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❖
CHAPTER 26
continued
PROCEDURAL STEPS
RATIONALE
18. Change tubes until all tubes have been collected (Figure 26-34). Instruct the patient to open the hand.
Opening the hand releases some of the pressure on the vein before removing the tourniquet.
19. Release the tourniquet and remove the tube before removing the needle.
Removing the tube before FIGURE 26-34 Change tubes as removing the needed until all tubes have been needle from the collected. arm prevents blood from dripping from the end of the needle. The tourniquet should be released before removing the needle from the vein to eliminate blood squirting due to the pressure of the tourniquet.
20. Place a dry cotton ball above the site, withdraw the needle, and ask the patient to apply firm pressure to the site for two to five minutes.
Continuous pressure must be applied to stop the bleeding and prevent hematoma.
21. Engage the safety device and discard the used equipment according to OSHA standards (Figure 26-35).
Proper disposal of contaminated equipment reduces the possibility of accidental exposure to the health care worker.
22. Check the puncture site and apply a pressure bandage.
Always check the site before applying the bandage to be sure that bleeding has subsided.
FIGURE 26-35 Close the safety sheath over the needle and deposit the entire unit into the sharps container.
23. Dismiss the patient. 24. Clean the work area. 25. Remove gloves and wash your hands. 26. Document the procedure in the patient’s chart.
Include the phlebotomy method, location, tests ordered, types of tubes drawn, and the name of the laboratory where tests were sent.
DOCUMENTATION EXAMPLE:
02-12-XX 10:30 a.m.
Phlebotomy, (vacuum tube method) R. antecubital for CBC and Executive profile per Dr. Smith. 2 red tops and 1 lavender top sent to ABC Labs. –complications. Carson O’Brien, CMA (AAMA)
COLLECTING THE BLOOD SAMPLE
❖
PROCEDURE 26-3 Venipuncture (Butterfly Method) Objective: To obtain a venous blood sample for laboratory testing from small, fragile veins that could easily collapse using other methods.
Equipment/Supplies: ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖
Gloves PPE Tourniquet Alcohol wipes Cotton balls Adhesive bandage Vacuum tube holder/syringe Vacuum tubes, usually short draw or pediatric size
PROCEDURAL STEPS
❖ Safety device (if performing the syringe method) ❖ Butterfly needle (21 to 25 gauge, 1⁄2 to 1 inch) ❖ Sharps container ❖ Patient’s chart RATIONALE
1. Check the provider’s order and complete the laboratory requisition form.
Always verify that tests being drawn are correct according to provider’s orders.
2. Wash your hands and apply PPE. Remember that the types of PPE worn during a blood draw may vary from one facility to another.
PPE must be worn to protect the individual collecting the specimen. The more types of PPE worn, the more you will be protected.
3. Assemble all the necessary equipment and label all tubes.
Labeling tubes before the draw eliminates the possibility of error later.
4. Identify the patient using two identifiers, and identify yourself.
Always clearly identify the patient before collecting the blood sample to be sure you are collecting the specimen from the correct person.
5. Explain the procedure.
If the patient is informed about the procedure, the patient will be more relaxed and less fearful.
6. Verify compliance of fasting instructions and other restrictions (for instance, the need to draw blood from one side or another due to a mastectomy or the presence of a shunt).
If the patient is not compliant with certain fasting instructions, the sample will have to be drawn at another time, or test results could be adversely affected. Drawing blood from the side on which patient has had a mastectomy may result in lymphedema.
7. Visually inspect the patient’s skin and veins in both arms or hands. Always ask if the patient has a preference. Patients usually know which veins produce the best results.
Entering the needle in edematous tissue, areas with burns, or other inflamed tissue may cause damage to the patient. Checking the veins in both arms will ascertain that you are using the best site possible.
8. Select the appropriate arm or hand and apply a tourniquet 3 to 4 inches above the elbow or wrist when drawing from the hand. The tourniquet should not remain in place longer than one minute.
Applying the tourniquet too close to the puncture site can cause a decrease in the flow of blood, making the blood sample more difficult to obtain. Leaving the tourniquet in place too long can cause hemoconcentration. continues
645
646
❖
CHAPTER 26
continued
PROCEDURAL STEPS 9. Ask the patient to make a fist.
RATIONALE Making a fist helps to enlarge the vein.
10. Place the fist of the patient’s other hand under the elbow when drawing from the arm, or under the wrist when drawing from the hand.
This helps to keep the arm or hand positioned correctly.
11. Palpate the vein and selected final site.
Always palpate the vein upward and downward to determine its direction.
12. Cleanse the site with alcohol using a circular motion.
This cleanses the skin of surface bacteria in the puncture area and decreases the risk of infection from the puncture.
13. Allow the area to air dry, or dry wipe the area with a clean/sterile cotton ball.
Dry wiping the area decreases the waiting time before puncturing and also decreases the chances of carrying alcohol into the puncture site, which may sting.
14. Pull the skin taut.
This keeps the vein from rolling.
15. Grasp the wings of the butterfly and insert the needle bevel up, at a 5° to 10° angle (Figure 26-36).
The needle must be bevel up for easy blood flow. When performing hand sticks, the degree is much shallower than in other methods of venipuncture to FIGURE 26-36 Grasp the wings and facilitate entry insert the needle. into the surface veins of the hand.
16. Vacuum Tube Method Once blood enters the tubing, push the tube onto the needle inside the tube adapter and allow it to fill completely. Remove the tube and invert additive tubes to mix before pushing in additional tubes. When the last tube is filling, release the tourniquet. When the tube is completely full, withdraw the tube and then withdraw the needle. Engage the safety device. Syringe Method Once blood enters the hub of the needle, start pulling back on the plunger. Fill the syringe completely and ask the patient to relax the hand. Release the tourniquet, withdraw the needle, engage the safety device, and remove the needle, placing it in a sharps container. Fill the tubes using a safety transfer device, and immediately invert them to mix. 17. Place a dry cotton ball over the site and instruct the patient to apply firm pressure to the site for two to five minutes.
Mixing additive tubes immediately before beginning to fill another tube will prevent the possibility of microclot formation. Relaxing the hand and releasing the tourniquet before removing the needle helps to eliminate the possibility of blood squirting.
Continuous pressure must be applied to stop bleeding and prevent hematoma. Proper disposal of contaminated equipment reduces the possibility of accidental exposure to the health care worker.
COLLECTING THE BLOOD SAMPLE
PROCEDURAL STEPS
❖
RATIONALE
18. Discard used equipment according to OSHA standards. 19. Check the puncture site and apply a pressure bandage.
Always check the site before applying the bandage to be sure that bleeding has subsided.
20. Dismiss the patient. 21. Clean the work area. 22. Remove gloves and wash your hands. 23. Document the procedure in the patient’s chart.
Include the phlebotomy method, location, tests ordered, types of tubes drawn, and the name of the laboratory where tests were sent.
DOCUMENTATION EXAMPLE:
02-12-XX 11:25 a.m.
Phlebotomy (butterfly method) R. antecubital for PT, PTT, and INR per Dr. Price. 1 blue top sent to ABC Labs. Patient c/o slight pain during procedure. Advised to apply ice upon returning home per Dr. Price. Addision Miller, CMA (AAMA)
PROCEDURE 26-4 Perform a Capillary Puncture Objective: To collect a capillary blood sample by the correct method to be used for laboratory testing.
Equipment/Supplies: ❖ ❖ ❖ ❖ ❖ ❖
Gloves PPE Alcohol wipes Cotton balls Adhesive bandage Sterile disposable lancet
PROCEDURAL STEPS
❖ Sharps container ❖ Supplies for tests ordered ❖ Patient’s chart RATIONALE
1. Check the provider's order and complete the laboratory requisition form.
Always verify that tests being drawn are correct according to provider’s orders.
2. Wash your hands and apply PPE. The types of PPE worn during a capillary stick may vary from one facility to another.
PPE must be worn to protect the individual collecting the specimen. Wearing all PPE will decrease your risk of contamination.
3. Assemble all the necessary equipment and label all tubes.
Always assemble extra equipment in case of a problem to eliminate the need for a second capillary stick. Labeling tubes before the puncture helps to eliminate error later. continues
647
648
❖
CHAPTER 26
continued
RATIONALE
PROCEDURAL STEPS 4. Identify the patient using two identifiers and identify yourself.
Always clearly identify the patient before collecting the sample to be sure you are collecting the specimen from the correct person.
5. Explain the procedure.
If the patient is informed about the procedure, the patient will be more relaxed and less fearful.
6. Select the fleshy portion of the patient’s distal middle or ring finger on the nondominant hand.
Using the nondominant hand will result in less pain for the patient throughout the day.
7. Apply a warm compress to the area or have the patient run the hands under warm water.
This will open up the blood vessels in the area, promoting better blood flow.
8. Clean the site with alcohol and allow it to air dry (Figure 26-37).
Dry wiping with a cotton ball is not advisable during this procedure, as small pieces of lint from the cotton ball could be left behind on the fingertip and could be carried into the puncture site.
9. Grasp the finger securely and puncture the fingertip at a right angle to the fingerprint (Figure 26-38).
Puncturing the fingertip across the fingerprints, not parallel to them, will provide a better blood sample.
10. Dispose of the lancet in the sharps container according to OSHA guidelines (Figure 26-39).
Proper disposal of sharps reduces the possibility of accidental needlesticks.
11. Wipe away the first drop of blood before beginning the sample collection.
The first drop of blood can be diluted with tissue fluid, resulting in an erroneous result.
12. Hold the finger, applying pressure by gently squeezing and releasing the fingertip (Figure 26-40).
Gentle pressure to the finger will increase blood flow.
13. Collect needed samples either in a capillary tube or microcollection tube (Figures 26-41 and 26-42). 14. Ask the patient to apply gentle pressure with a clean, dry cotton ball to the puncture site.
Pressure will help to stop bleeding and decrease bruising at the puncture site.
15. Check the puncture site and apply a bandage, if necessary.
Never allow the patient to leave before checking the site to make sure the bleeding has stopped.
FIGURE 26-37 Cleanse the tip of the
FIGURE 26-38 Lance the tip of the
FIGURE 26-39 Immediately dispose
finger with alcohol.
finger.
of the used lancet.
COLLECTING THE BLOOD SAMPLE
FIGURE 26-40 Apply gentle pressure to collect a drop of blood.
FIGURE 26-41 Collect the specimen into a capillary tube.
PROCEDURAL STEPS
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649
FIGURE 26-42 Collect the specimen into a microtainer tube.
RATIONALE
16. Dismiss the patient. 17. Properly dispose of all used equipment according to OSHA standards.
Disposing of contaminated equipment reduces the possibility of accidental exposure to the health care worker.
18. Clean the work area. 19. Remove gloves and wash your hands. 20. Document the procedure in the patient’s chart.
Include the collection method, location, and tests performed.
DOCUMENTATION EXAMPLE:
11-08-XX 12:30 p.m.
Capillary puncture, R.middle finger. 2 heparinized capillary tubes collected for microhematocrit per Dr. Christoper. Hct. 28%. Jessica Hunnicutt, CMA (AAMA)
Chapter Summary Venipuncture is a skill that becomes easier with practice. The medical assistant must become proficient at this skill in order to provide the laboratory with the best specimen possible and the provider with the necessary test results. Good phlebotomy skills will come with time and practice. Precise and accurate collection practices must be followed in order to provide the laboratory with the best quality specimen for testing. Accurate test results depend upon correct collection, processing, and handling procedures. There is no room for error or shortcuts in this area. Decisions about diagnosis and treatment depend upon the laboratory results obtained. Practice is essential to become proficient in this area.
650
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CHAPTER 26
FIELD APPLICATION CHALLENGE While you were performing a venipucture on a patient, you noticed that the patient was wincing and in pain. The blood was flowing slowly but steadily into the tube so you continued filling all tubes for the tests ordered. After completing the venipuncture, you instructed the patient to apply pressure to the puncture site for a minimum of two to five minutes. You then applied a bandage without checking the site and dismissed the patient. Several minutes later, the patient returned complaining of discomfort at the puncture site. After checking the site, you discovered a large hematoma.
1. What steps should you have taken when the patient appeared to be uncomfortable? 2. What could be the result of a tube that fills slowly? 3. What steps should you have taken to prevent hematoma from occurring? 4. What should you do now that the patient has a hematoma?
Chapter Assessment 1. When transporting vacuum tubes to the laboratory, they should be: a. protected from light. b. placed on ice. c. placed in a heating block. d. kept in an upright position.
6. The medical assistant should only attempt a venipuncture on a patient: a. three times. b. two times. c. once. d. as many times as necessary.
2. A failed venipuncture can occur for all the following reasons except: a. insufficient tube vacuum. b. collapsed vein. c. needle inserted bevel up. d. needle bevel is against the wall of the vein.
7. When filling the following tubes from a syringe draw, which tube should be filled first? a. Lavender b. Red c. Green d. Blue
3. Failure to invert additive tubes can result in: a. hematoma. b. hemolysis. c. lipemia. d. microclot formation.
8. The most common vein selected to perform a venipuncture is: a. cephalic. b. median cubital. c. antecubital. d. brachial.
4. The anticoagulant of choice for most hematology studies is: a. sodium citrate. b. EDTA. c. sodium fluoride. d. lithium heparin. 5. The butterfly method should be used: a. routinely. b. for hand sticks. c. rarely. d. for large veins.
9. Leaving the tourniquet in place longer than one minute can cause: a. hematoma. b. hemostasis. c. hemoconcentration. d. viscosity.
COLLECTING THE BLOOD SAMPLE
Web Activities 1. Visit the Web site for the American Society of Phlebotomy Technicians at http://www.aspt.org and research the requirements for certification. 2. Visit the Web site for the American Society of Clinical Pathologists at http://www.ascp.org for information on certification and job availability for medical assistants as phlebotomists.
CONNECTION Using your StudyWARE CD-ROM: ❖ Complete the Crossword Puzzle activities for this chapter. ❖ Complete the Quiz for this chapter in Test Mode.
❖
651
THE DVD LINK On your StudyWARE CD-ROM, go to the DVD Challenge for this chapter. View the DVD clip and respond to the following questions: 1. What can happen if you leave the tourniquet on for a prolonged period of time? 2. Besides making certain that you have the right patient, what else should you verify prior to performing a blood draw? 3. In reference to the testimonial from Lori regarding the gentleman who fainted during a blood draw, what signs did the patient display that warned Lori that this patient was in trouble? What would you do if you had a patient that displayed signs of extreme nervousness or anxiety prior to the blood draw? What would you do if the patient didn’t display any signs of anxiety until you were in the middle of the blood draw?
C H A P T E R
Urinalysis
Essential Terms
Chapter Outline Composition of Urine Specimen Collection Urine Specimen Containers Methods of Collection Quality Control Routine Urinalysis Physical Examination Color Clarity/Turbidity Specific Gravity
27
Chemical Examination Quality Control for Reagent Test Strips Reagent Strip Analyzers Confirmatory Tests Clinitest Ictotest Acetest Sulfosalicylic Acid (SSA) Test Microscopic Examination
Developmental Objectives After completing this chapter, you should be able to: 1. Correctly spell and define the essential terms. 2. List and describe the different methods of specimen collection for urine testing. 3. Describe the use of different specimen containers and the rationale for each. 4. Discuss the importance of quality control and proper record keeping. 5. List the three parts of a complete urinalysis and describe the test methods employed in each.
bilirubin cast clean-catch midstream specimen first-morning specimen hematuria hemoglobinuria ketone pH random collection reagent test strip refractometer renal threshold sediment specific gravity supernatant turbid urea urinalysis urochrome void
URINALYSIS
KEY COMPETENCIES
❖
CAAHEP
ABHES
Instructing a Patient on Clean-Catch Midstream Urine Collection
III.C.3.b.1.e III.C.3.b.2.d
VI.A.1.a.4.w VI.A.1.a.4.r
Performing a Complete Urinalysis
III.C.3.b.1.d III.C.3.b.1.e III.C.3.b.3.c
VI.A.1.a.4.k VI.A.1.a.4.q VI.A.1.a.4.y
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6. List the confirmatory tests for glucose, bilirubin, and ketones. 7. Describe the proper technique for preparing a slide for microscopic examination. 8. Record the normal values for a chemical and microscopic urinalysis and state the clinical significance of abnormal readings.
Introduction Urinalysis is one of the most frequently performed tests in the physician’s office laboratory (POL). The specimen (urine) is plentiful, easily collected, and numerous tests can be performed on a single aliquot (portion of the whole specimen). Test results can offer the provider a multitude of information about different body systems, disease states, and metabolic processes occurring within the body. A routine urinalysis is usually performed as part of a complete physical exam and consists of the physical, chemical, and microscopic examination of urine. Precision and accuracy are critical when performing a urinalysis in order to give the provider quality results.
COMPOSITION OF URINE Urine is produced in the kidneys as they filter the blood. Once it is formed, it consists of approximately 95% water and 5% dissolved substances. The following are the primary substances found in the urine: ❖ ❖ ❖ ❖ ❖ ❖ ❖
Urea Uric acid Creatinine Ammonia Calcium Magnesium Phosphorous
Other substances can also be found in urine, depending on a person’s diet and general state of health. If there are pathological conditions present, substances such as glucose, albumin, ketones, blood, pus, casts, and bacteria may also be found in the urine. Certain substances such as glucose are usually entirely reabsorbed by the body if they are present in the blood at normal levels. However, if the concentration of a substance in the blood is so high that the kidneys cannot reabsorb all of it, the excess spills into the urine and is detected by chemical urinalysis. When substances that are not normally present in the urine of healthy individuals are
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F IEL D S M A R T S
PATIENT TUTOR
A great deal of information can be gained from the results of a simple urinalysis test. Urine is plentiful, easily collected, and results can often be obtained quickly right in the medical office. However, the test results are only as good as the specimen collected. Correct specimen collection and handling are critical to ensure accurate results.
Patients who bring in a urine specimen collected at home should be educated on the type of container to use as well as proper collection technique. Whenever possible, the patient should be encouraged to run the container through the dishwasher prior to collection. This will provide an environment that is close to sterile. Advise patients to refrain from using containers that previously held medicine, vitamins, soap, or other cleaning agents if the container cannot be boiled or put in the dishwasher before collection. Even slight residue left in empty containers that contained the previous agents can cause inaccurate results on most of the chemical tests performed.
detected, the renal threshold has been reached and usually indicates the presence of an abnormal condition or disease.
SPECIMEN COLLECTION General urine specimen collection guidelines are as follows: ❖ Collect a sufficient volume of urine (minimum of 10 to 12 mL). ❖ Properly label the specimen. ❖ Avoid collecting a urine specimen from women during menses. If a specimen must be collected during menses, it must be noted on the laboratory requisition form. ❖ List all current medications being taken by the patient. ❖ Make sure the patient fully understands the collection procedure. ❖ Be patient when explaining the collection procedure. ❖ Specimens must be refrigerated if testing cannot be completed within one to two hours of collection.
Urine Specimen Containers
FIGURE 27-1 One example of a urine specimen container
A variety of different containers are available for urine collection (an example is shown in Figure 27-1). A nonsterile container is generally used for random specimen testing and consists of a clean, dry container with a tight-fitting lid. Special sterile containers should be used when there is a probability that a urine culture will be ordered, such as when a patient displays urinary symptoms. A sterile container is always used for
specimens that come from a patient that was catheterized. A 24-hour urine collection requires a container into which a preservative has been added. All urine containers must be properly labeled before the specimen is collected. Labeling requirements may vary by facility, but generally include the following: ❖ ❖ ❖ ❖ ❖ ❖
Patient’s name Age Gender Date of collection Time of collection Provider’s name
Labels should be placed on the container itself and not on the lid. Lids are removed for testing—if discarded, the label could be lost.
Methods of Collection Different methods of collection may be required to obtain accurate test results. The type of test requested will determine the type of specimen and the method of collection. The following are common methods of collection used in provider’s offices.
Random Collection A random collection method is used to collect urine that requires no special preparation and is normally collected in a nonsterile container. Random collection is the easiest of all urine collections, which is why it is used so often. This type of collection is not connected
URINALYSIS
to a specific time, which is how it got its name. It is used most often when just a chemical analysis of the urine is necessary, such as in OB patients having their glucose and protein tested. Collection by this method often produces inaccurate results of the microscopic exam due to contamination of the specimen by epithelial cells, bacteria, mucous, and feces. Therefore, this method of collection should not be used when there are any signs of urinary tract infection that may indicate the need for further testing (such as a microscopic analysis of the urine or culture and sensitivity testing).
First-Morning Specimen The first-morning specimen is collected when the patient voids for the first time after waking. Since the first-morning specimen contains the greatest concentration of dissolved substances, a small amount of an abnormal substance can be easily detected. The patient is instructed to place the specimen in the proper container and refrigerate it to preserve it until it can be brought to the office for testing. The first-morning specimen is most commonly used for routine urinalysis and pregnancy tests.
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Clean-Catch Midstream Specimen The distal urethra and the urinary meatus usually contain normal flora (nonpathogenic bacteria normally present), which can interfere with test results. For this reason, providers will usually request a clean-catch midstream specimen, especially for culture and sensitivity testing. This method flushes the normal flora from the urethra and urinary meatus before the specimen is collected. By using this method of collection for bacterial culture and sensitivity testing, it eliminates the need to collect the specimen by catheterization. The initial step in collecting a clean-catch midstream specimen is to cleanse the genital area with an antiseptic towelette. Men should be instructed to cleanse the urethral meatus using the antiseptic towelette with a single stroke from the tip of the penis toward the ring of the glans. This process should be repeated a second time using a clean towelette (Figure 27-2). Females
FIGURE 27-2 The proper cleansing method for males for a clean-catch midstream urine
Fasting/Timed Specimen
F IELD SM A RTS Urine specimen containers should be handled following the precautions below: ❖ All body fluid specimens, including urine, should be considered potentially infectious. ❖ PPE such as a face mask, goggles, waterproof gown, and gloves should be worn to protect the medical assistant against possible splashes, especially when disposing of the urine. ❖ Urine should be tested as soon as possible.
❖ Urine specimens should be stored in refrigerators that are not used for food or drinks. ❖ Properly dispose of urine specimens by pouring the specimen down the drain of the “dirty” sink while running water. A “dirty” sink is used to dispose of specimens such as urine, while a “clean” sink should only be used for handwashing. Some facilities instruct their medical assistants to dispose of urine specimens down the toilet.
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Specimens are usually collected by this method to prevent any interference from food or liquids consumed by the patient. Patients may be asked to fast overnight or to collect a specimen after eating a meal. Patient education on proper collection technique is critical to obtain a specimen that will yield accurate results. Timed specimens are used for two-hour postprandial testing (two hours after a meal), glucose tolerance tests, and glucose challenge tests (one to two hours after a meal or after ingesting a concentrated glucose solution).
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FIGURE 27-3 The proper cleansing method for females when collecting a clean-catch midstream urine
should be instructed to spread the labia apart using one hand and cleanse the inner portion of the fold on the right side, with a front-to-back motion, using one antiseptic towelette. The process should be repeated on the left side using another towelette. A third towelette should be used to cleanse the urethral meatus itself with a single front-to-back motion (Figure 27-3). After thoroughly cleansing the genital area, the patient should be instructed to collect the midstream portion of the urine flow, while still retracting the labia folds. The patient should begin voiding into the toilet, then catch a portion of the stream in a sterile specimen container, and finish voiding into the toilet. A specimen collected by this method is as free of contamination as possible. Printed instructions should be posted in patient restrooms where collection takes place. Refer to Procedure 27-1 for a full procedure.
Catheterization Collecting a urine specimen by catheterization requires passing a sterile tube through the urethra into the bladder to obtain a sterile specimen for culture and sensitivity. Catheterizations are usually performed by the provider in most medical offices; however, some providers will train the medical assistant to perform this procedure. Since male catheterizations are more difficult and painful for the patient due to the length of the urethra, the provider may prefer to perform catheterizations on all male patients, while the medical assistant may perform catheterizations on all female patients. Additional information, along with the procedure for catheterization, can be found in Chapter 18. Because this type of specimen collection is invasive and somewhat painful for the patient, extra care
should be taken when handling the specimen to avoid the need to collect the specimen again. Since a catheterized specimen is sterile, it must be placed in a sterile collection container. The provider will usually order a culture and sensitivity test on this type of specimen. The medical assistant is usually responsible for preserving the urine and preparing the specimen for transportation to the lab. A special transport kit (Figure 27-4) for a urine culture and sensitivity test is used when sending the specimen to the laboratory (for more information, refer to Procedure 29-1).
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C R I T I C A L T H I N K I NG CHALLENGE You receive a call to come to the front desk and pick up a specimen that was left by a patient. You obtain the specimen, which is in a brown paper bag. Upon further inspection, you discover that it is a urine specimen in a mayonnaise jar. The jar still looks greasy and doesn’t appear to be very clean. The patient’s name is on the specimen but the date or time of collection is not listed. 1. Should you call the patient to obtain additional information? If so, what information will you need? 2. Should you check with the provider prior to testing? Explain your answers.
URINALYSIS
24-Hour Urine Collection Certain substances, such as protein, glucose, creatinine, calcium, and electrolytes, can vary in concentration in the urine over a 24-hour period. Factors such as exercise, metabolism, and food and water intake can affect the amount of a substance present in a randomly collected urine sample. For that reason, quantitative tests, which measure the specific amount of a substance present, can be performed by collecting a 24-hour urine specimen. Explicit and detailed instructions must be provided to the patient to ensure an accurate collection. A large, dark-colored container is provided for the patient to collect all urine voided over a 24-hour period (Figure 27-5). Some analytes require a preservative to be added to the collection bottle to preserve the integrity of the specimen. Early morning is the most common time to begin a 24-hour collection. The patient is instructed to void and discard the first-morning specimen on the first day of collection and note the time the collection begins. All urine is then collected over the next 24 hours. A smaller container is used to collect each specimen and is then poured into the large container following collection. Every time urine is added, the collection container must be returned to the refrigerator to preserve the specimen, unless a preservative was added. At the end of the 24-hour period, the first specimen of the second morning is collected and added to the collection bottle and the time is noted (the time the collection ended). The specimen should be returned to the office or laboratory as soon as possible. The total volume of
FIGURE 27-4 A urine culture transport system
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E M R A P P L I C AT I O N Many EMR software programs store educational materials. If the patient loses the written instructions, all the medical assistant has to do is to click on the educational handout icon and pull up the appropriate instructions. Once the instructions are displayed, the medical assistant can either fax or e-mail the directions directly to the patient. This saves the patient a trip back to the office and the medical assistant time in gathering the information.
urine voided is accurately measured and recorded on the laboratory requisition form. An aliquot or portion of the well-mixed specimen is sent to the laboratory for quantitative analysis, and the remaining urine is discarded.
FIGURE 27-5 A 24-hour urine specimen collection container
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Pediatric Urine Collection The parent often is asked to collect a pediatric urine sample at home. Detailed written instructions should be provided to avoid problems with the collection process. A special collection bag that attaches to the infant’s skin over the genital area (Figure 27-6) is used to collect the urine. Once the specimen has been collected, it is transferred to a specimen container for transport to the medical office or laboratory.
QUALITY CONTROL
FIGURE 27-6 An example of a pediatric urine collection system
F IELD SM A RTS Troubleshooting in the POL can be quite difficult. When a problem arises, such as a control result that is not within range, an unexpected test result on a patient sample, or an instrumentation problem, you must be able to troubleshoot, or discover and solve the problem. This process involves a logical step-by-step investiga-
tion of all phases of the testing process. Patience and perseverance are required to solve these issues when they occur. Start the troubleshooting process by reviewing each aspect of the test method, including instrumentation, until the problem is resolved.
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Quality control is important to ensure precise, accurate, and reliable test results in every area of laboratory testing, including urine testing. Regulatory agencies require medical facilities to include quality control as part of urine testing procedures. According to CLIA regulations, the manufacturer’s directions should be followed regarding how often controls should be preformed on dipsticks or urine analyzers. Control samples should be tested along with patient samples using the same test methods for each. All control sample results must be recorded in a control log, and documentation of these results must be kept for at least three years. Figure 27-7 illustrates an example of a control log sheet. Urine quality control products are available from several different manufacturers, one of which is discussed later in the chapter. Controls must be prepared and stored according to specific manufacturer’s directions. Each manufacturer will provide an acceptable value range for the specific control sample. If the control does not fall within the acceptable range of results, patient results cannot be reported until the problem is corrected.
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URINALYSIS TEST STRIP QC LOG Date
Test Strip Name
Manufacturer’s Name
01/11/09 V - Stix 12 KLM Diagnostics
Lot#
12230V
Exp Date
Name of Control
Lot #
Exp Date
06/12 V Control 45621LV3 11/10
Were all results Initials within control ranges (List any that were not within control ranges.)
Yes
TJ
FIGURE 27-7 A quality control log sheet
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CR ITI C A L TH I N K I N G C H AL LEN G E After performing chemical urinalysis on 10 patient urine samples and reporting the results, you realize that you opened a new bottle of reagent strips and did not perform a control. The manufacturer’s instructions state that you must perform a control whenever you open a new bottle of test strips. 1. What should you do?
ROUTINE URINALYSIS The routine urinalysis is one of the most commonly performed tests in the medical office. This simple test can supply the provider with information about the urinary tract as well as other body systems. It is often performed as part of a complete physical exam or used as a diagnostic tool when a specific condition is suspected. A urine specimen must be tested within one to two hours of collection. If testing is not possible within that time frame, the specimen must be refrigerated to preserve the components (if the specimen has been refrigerated, it must be brought to room temperature before testing). Table 27-1 lists possible changes that can occur if urine is allowed to stand at room tempera-
ture beyond the one- to two-hour time limit. A routine urinalysis consists of three parts: physical, chemical, and microscopic examination.
PHYSICAL EXAMINATION The physical portion of the urinalysis consists of observations about the color, clarity, and specific gravity of the urine. Volume should be assessed to determine if the quantity is sufficient for testing. For accurate testing, 10 to 12 mL of urine is usually necessary. Volume requirements will vary by facility. If the volume is found to be insufficient, the letters “QNS” (quantity not sufficient) should be noted on the requisition form and the urine should not be tested. Urine odor is not usually recorded as part of the physical urinalysis; however, any abnormal odor should be noted. A foul odor could indicate an increase in bacteria, which could indicate infection, whereas a sweet, fruity odor could indicate a potentially serious condition known as ketoacidosis (a condition that occurs in patients with uncontrolled diabetes). Foam found on freshly voided urine can be indicative of certain conditions: ❖ “Lasting” white foam may denote increased protein, which could signal renal disease. ❖ A deeply pigmented yellow foam on top of yellow-brown or yellow-green urine may indicate increased bilirubin, which could be a result of hepatitis.
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TABLE 27-1 Changes in Improperly Preserved Urine Specimens COMPONENT
POSSIBLE CHANGES
Clarity
Becomes cloudy due to bacterial growth
Odor
Can become stronger due to bacterial growth and the breakdown of urea to ammonia
pH (acidity or alkalinity)
Increases due to bacterial growth
Glucose
Decreases due to utilization of glucose as a food source by bacteria
Ketones (normal products of fat metabolism)
Decrease due to the conversion of ketones to acetone, which is not detectable by the reagent strip
Bilirubin (product of the breakdown of red blood cells)
Decreases due to breakdown when exposed to light
Urobilinogen
Decreases due to breakdown as a result of oxidation
Nitrite
Increases due to multiplication of bacteria
Red blood cells (RBC) and white blood cells (WBC)
Decrease due to the breakdown of the cells
Casts (structures formed due to accumulation of protein in the renal tubules)
Decrease due to decomposition
Bacteria
Increase due to multiplication
Color The color of urine is produced by an orange-yellow pigment known as urochrome. Normal colors range from straw (almost colorless) to amber (see Figure 27-8).
FIGURE 27-8 Normal urine colors
Abnormal colors may indicate a pathologic condition or may be caused by certain drugs or foods. Table 27-2 lists urine colors and their possible significance.
Clarity/Turbidity Freshly voided urine should be clear, but may become cloudy upon standing. Cloudy urine can have a nonpathologic cause, such as squamous epithelial cells or mucous (especially in female patients). The most common pathologic causes of urine cloudiness are bacteria, white blood cells, red blood cells, protein, or lipids. Semen, fecal contamination, vaginal creams, and powder can also affect the clarity of the urine. To evaluate the clarity of the urine, the specimen should be mixed well, placed in a clear container, and held in front of a light source. Common terms used to describe urine clarity are clear, hazy, cloudy, or turbid (opaque or unable to see through the specimen), but can vary from one facility to another. The medical assistant should become proficient at determining urine clarity. Figure 27-9 shows examples of urine clarity.
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TABLE 27-2 Urine Colors and Causes COLOR
POTENTIAL CAUSE
Colorless
Very dilute urine; diabetes insipidus; chronic renal disease
Straw to yellow
Normal color
Dark yellow/amber
Very concentrated urine; first-morning specimen; vomiting, excess fluid loss, or excessive exercise (the result of dehydration)
Orange
Antibiotics used to treat urinary tract infections (UTIs)
Cloudy pink, red, or reddish/brown
Hematuria: intact red cells present in the urine; menstrual contamination Hemoglobinuria: red cells have ruptured and hemoglobin has been released into the urine
Yellow/brown or yellow/green
Bilirubin present; bilirubin converted to biliverdin
Green or blue/green
UTI caused by Pseudomonas bacteria; antidepressants such as Amitriptiline; Clorets
Brown
RBCs oxidized to methemoglobin; should see a positive test for blood
Black
Presence of melanin pigment; homogentisic acid seen after urine stands; certain antihypertensives; Flagyl (an antibiotic)
Specific Gravity The specific gravity of urine provides information on the kidneys’ ability to concentrate and dilute urine. It measures the concentration of dissolved substances present in the urine by comparing the weight of the urine to the weight of an equal volume of distilled water. The more concentrated the urine, the higher the specific gravity. For instance, in diabetes mellitus, the presence of dense (heavy) glucose molecules in the urine causes the specific gravity to be high. Normal value range for specific gravity is 1.003 to 1.030, but may vary slightly from one facility to another.
FIGURE 27-9 Clarity of urine
Several methods are used to measure urine specific gravity, including the refractometer and reagent test strips. The reagent strip is classified as a waived test by CLIA ’88 along with a refractometer that yields a digital readout.
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FI E L D S M A R T S Many offices use the urine dipstick as the means of measuring specific gravity. It is easy to perform and requires less work than other methods. Some offices, such as endocrinology and urology practices, may prefer to use a refractometer because it can give a more precise measurement (down to the nearest tenth). Dipstick results can vary by several numbers from one test pad to the next, making it difficult to get an exact reading. In diseases such as diabetes insipidus, it is important to get an exact specific gravity reading. This disease is a rare metabolic disorder caused by a deficiency of an antidiuretic hormone known as vasopressin. Patients with diabetes insipidus excrete large quantities of very dilute urine and suffer from polyuria (excessive urination) and polydipsia (excessive thirst). When dealing with conditions such as this, it is better to use the more exact refractometer method over the dipstick.
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Refractometer 320
The refractometer is a device used to measure specific gravity. The instrument is usually handheld and consists of a lens and a prism (Figure 27-10). The refractometer measures the refractive index of the urine, which is directly proportionate to the specific gravity. This method requires only one to two drops of urine, and the results are read directly from a calibrated scale. Figure 27-11 shows the scale within the refractometer. CLIA has now approved a new refractometer that produces a digital readout. This digital readout test is now a waived test and can be performed by medical assistants (Figure 27-12).
310 15
FIGURE 27-10 Refractometers
260 250
12
240 230
11
220 210
SERUM OR PLASMA PROTEIN GMS /100 ml
T/C PR /N RATIO 6.54
10
8
6 1.035 1.030
T/C
200 190
9
7
URINE
The second part of a complete urinalysis is the chemical exam. Results from this part of the analysis can provide the practitioner with valuable information about the patient’s kidney and liver function, carbohydrate metabolism, and acid-base balance in a short period of time. Positive chemical test results will require further evaluation with confirmatory tests, discussed later in this chapter. The chemical exam is performed using a reagent test strip or dipstick. The reagent test strip consists of a narrow plastic strip with pads attached that have been treated with specific chemicals. When dipped in
280 270
13
SPECIFIC GRAVITY
CHEMICAL EXAMINATION
300 290
14
5
180 170 160 150 140 130
REFRACTION
120
(N-No) ⫻ 104
110
T/C
100
1.025
4
1.020
3
90 80 70 60
1.015
50 40
1.010 1.005
30 20 10
1.000
0
FIGURE 27-11 A refractometer scale as it would appear in a refractometer
FIGURE 27-12 A digital refractometer (Courtesy of MISCO Refractometer.)
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F IELD SM A RTS Several factors can impact the integrity of chemical reagent strips, including expiration of the sticks, moisture, and temperature. Always check the expiration date on the bottle before using. Rotate stock when new stock comes in to avoid expiration. Store dipsticks in a clean dry environment at the temperature listed on
urine, the pads will change color due to a chemical reaction, indicating the presence of certain substances in the urine. Reagent strips come in an opaque bottle (to protect the test pads from light), must be stored at a specific temperature range, and must be protected from moisture. When performing the reagent strip test, only the number of strips to be used should be removed. The bottle should be recapped immediately to protect the strips from moisture and light. Reagent test strips are available from several different manufacturers and each type may vary slightly. Always follow individual manufacturers’ recommendations for handling the strips and the timing of test results. Multistix 10 SG® will be referenced in this text. Figure 25-13 shows the reagent strip and the reference chart found on the bottle. Chemical analysis of urine using a reagent test strip requires precise timing of the readings to ensure accurate results. Table 27-3 lists the chemical tests available on the Multistix 10 SG reagent test strips, the normal values, and the clinical significance of positive results. See Procedure 27-2 for the steps necessary to perform a complete urinalysis.
FIGURE 27-13 Multistix 10 SG reagent strips
the bottle. One sure indicator that strips have been compromised is any color change on the test pads. Always check the test pads on the dipstick upon removing them from the bottle. If the color of the pads of the dipsticks does not match the first row on the color chart on the bottle, the sticks should not be used.
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URINALYSIS
A relatively new reagent strip, the Multistix PRO LS®, is the only strip that provides all of the tests listed in Table 27-3 as well as a protein-creatinine ratio. This ratio is useful in evaluating patients at high risk for developing renal disease.
Quality Control for Reagent Test Strips Reagent test strips must be tested using a commercially prepared control sample (Figure 27-14) with known value ranges to ensure that the strips and automated unit are in good working order. Control samples should provide both positive and negative results. Remember, patient results cannot be reported unless the results of the control sample fall within the expected range. If the control sample is tested and does not fall within the acceptable range, the following steps should be performed:
FIGURE 27-14 Chek-Stix urine control
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FI E L D S M A R T S You must take great care to read the urine strip correctly. Timing is crucial: The longer the test strip sits, the darker the colors turn, which will alter the reading. This will cause the results to not match the microscopic values. A discrepancy could result in the need for the patient to come back to the office for another test.
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TABLE 27-3 Multistix 10 SG Results COMPONENT
NORMAL VALUE
CLINICAL SIGNIFICANCE OF POSITIVE OR ELEVATED RESULTS
pH
4.5–8.0
Old specimen; UTI
Protein
Negative/trace
Renal disease; extreme exercise; high fever; dehydration
Glucose
Negative
Diabetes; pancreatic disease; advanced kidney disease
Ketones
Negative
Starvation; low-carbohydrate/high-fat diet; uncontrolled diabetes
Blood
Negative
Hemolytic anemias; kidney or urinary tract damage; menstrual contaminant
Bilirubin
Negative
Hepatitis; possible bile duct obstruction
Urobilinogen
0.1–1.0
Liver dysfunction; hemolytic diseases
Nitrite
Negative
UTI; cystitis; used to monitor antibiotic therapy
Leukocytes
Negative
UTI
Specific gravity
1.005–1.030
Kidney function; diabetes
❖ Recheck the expiration date of the strips. ❖ Recheck the expiration date of the control sample. ❖ Be sure that manufacturer’s directions were followed when preparing the control sample. ❖ Repeat the control testing, using either a new set of controls or new bottle of dipsticks if either was expired. If neither was expired and there were no other abnormalities detected, repeat the control testing again using the original products. If the results do not fall within the acceptable range this time, further troubleshooting will need to be conducted before any further testing is performed on patient specimens. Results of all controls and reagent lot numbers must be recorded in a quality control log, such as the one found in Figure 27-7.
Reagent Strip Analyzers Automated urine strip analyzers, such as the Clinitek 200®, are available for use in the medical office (Figure 27-15). The health care worker dips the reagent strip into the urine, blots it, and places it into the instrument. The instrument automatically reads the reagent strip and prints out the results. Although automated strip readers are quite expensive, they are used frequently in ambulatory care settings to provide more accurate results and help eliminate the possibility of human error. Recently, medical equipment manufacturers have come out with some waived urine strip analyzers that can be used in waived laboratories.
CONFIRMATORY TESTS Certain substances present in the urine and some medications can interfere with accurate reagent strip results. For that reason, when particular pads on the reagent strip are positive, they should be sent out for further evaluation. The following are examples of tests that can be confirmed with special confirmatory tests: glucose, protein, bilirubin, and ketones.
FIGURE 27-15 Chemstrip Mini UA Analyzer (Courtesy of Boehringer Mannheim)
URINALYSIS
Clinitest The Clinitest® is designed to detect the presence of certain reducing sugars, such as lactose and galactose, which are not detected by the dipstick. This confirmatory test uses a tablet and a color reaction chart to detect the quantity of sugar in the urine.
Ictotest The Ictotest® is a confirmatory test specific for bilirubin and is four times more sensitive than the reagent test strip. A test tablet is placed on an absorbent mat and flooded with several drops of urine. A purple color indicates the presence of bilirubin.
Acetest Ketones are present in the urine as a result of an increase in fat metabolism. The Acetest® is a confirmatory test for ketones. Figure 27-16 illustrates the Acetest method. A test tablet is placed on filter paper and drops of urine are placed on the tablet. If ketones are present in the sample, a purple color will appear.
Sulfosalicylic Acid (SSA) Test The sulfosalicylic acid (SSA) test is a confirmatory test for protein in the urine. If the dipstick is positive for more than just a trace of protein, the SSA test can be performed. A portion of the urine sample is placed in a test tube to which SSA is added. If protein is present, the urine will turn cloudy or turbid. The amount of protein in the urine is related to the degree of turbidity. For example, if the protein reads a 4+ on the dipstick, then the SSA test will yield a sample that is very thick and may have visible clumps of protein.
MICROSCOPIC EXAMINATION A microscopic exam of the urine sediment after centrifugation is the third part of a complete urinalysis. In most POLs, a physician will perform the microscopic analysis on the urine. CLIA categorizes this test as a FIGURE 27-16 Acetest to confirm ketones in the urine
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C R I T I C A L T H I N K I NG CHALLENGE A female patient comes in complaining of urinary symptoms. The symptoms have been present for three days. You ask the patient about current medications and the patient responds that no prescribed medications are currently being taken. The patient does, however, state that she is taking an OTC medication that is supposed to get rid of the infection. The patient does not remember the name of the medication and did not bring it with her. The symptoms have not subsided, which is why the patient is here for an appointment. You retrieve a urine sample and it is orange and very clear. When you insert the dipstick into the urine, each of the test pads turn a strange color that appears to coincide with the color of the patient’s urine. You are unable to read the test pads. 1. What might be contributing to the strange color of the urine? 2. What might be the cause of the test pads turning colors that are not on the color chart? 3. What should you do with the findings?
PPM (physician performed microscopy) procedure, which means that the medical assistant may not perform this portion of the urinalysis. However, the medical assistant may prepare the slide and place it on the microscope for the physician to read. In order to prepare the slide, the medical assistant will pour urine into a clear plastic tube and spin it in the centrifuge following manufacturer’s instructions. Once the centrifuge has come to a stop, the medical assistant will remove the tube from the unit and pour the supernatant (the clear liquid that remains after spinning the urine) out into the dirty sink. A small portion of the sediment (the solid material in the bottom of the tube) is then placed on a microscope slide for physician examination. Procedure 27-2 lists the steps for preparing a urine sediment slide. Urine sediment can be viewed under the microscope either with or without the use of a sediment stain. Many of the elements found in urine are very light and almost colorless when viewed under the microscope. A stain added to the sediment can make things easier to see by adding color to the elements.
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F IELD SM A RTS When performing a microscopic exam on a urine specimen, a valuable tool to have on hand for the physician performing the testing is a color atlas of urinary sediment. This atlas features pictures with the most common elements found in urine, along with significant information about each one. Table 27-4 lists the more common
elements, how they are reported, their normal value, possible pathological conditions, distinctive features, and possible sources of identification error. Make certain that there is an atlas nearby when the physician reads a microscopic urine slide for comparison studies.
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TABLE 27-4 Mini Atlas of Urinary Sediment CAUSES OF IDENTIFICATION ERROR
REPORTED AS:
NORMAL VALUE
PATHOLOGICAL CONDITIONS
DISTINCTIVE FEATURES
Hyaline cast
Range of numbers/LPF*
0–2/LPF
Congestive heart failure Acute glomerulonephritis Chronic renal pyelonephritis
Colorless with rounded ends
Hair Mucus Fiber
Red blood cell (RBC) cast cast
Range of numbers/LPF
0/LPF
Damage to glomerulus Nephron bleeding Proteinuria In a healthy individual, following strenuous exercise
Orange/red color
Clumps of RBCs
White blood cell (WBC) cast
Range of numbers/LPF
0/LPF
Upper UTI Pyelonephritis Differentiates upper UTI from lower UTI Internal inflammation of nephron
Granular appearance/ white cells have multilobed nuclei
Clumps of WBCs
Renal tubular epithelial cell cast
Range of numbers/LPF
0/LPF
Advanced tubular destruction Urinary stasis Heavy metal poisoning Viral infections
RTEs attached to the cast
WBC cast
ELEMENT
*Abbreviations used in this table: LPF: Low power field HPF: High power field RTE: Reticuloendothelial cells
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TABLE 27-4 Mini Atlas of Urinary Sediment (continued) CAUSES OF IDENTIFICATION ERROR
REPORTED AS:
NORMAL VALUE
PATHOLOGICAL CONDITIONS
DISTINCTIVE FEATURES
Granular cast
Range of numbers/LPF No longer differentiated as coarse or fine
0/LPF
Pyelonephritis Glomerulonephritis Stress and exercise
Coarse/fine granules contained within the cast
Clumps of crystals
Fatty cast
Range of numbers/LPF
0/LPF
Lipiduria Nephrotic syndrome Diabetes mellitus Crush injuries
Stain orange with special fat stains Very refractive
Fecal debris
Waxy cast
Range of numbers/LPF
0/LPF
Chronic renal failure
Very refractive Jagged ends with notched sides
Fecal debris Fibers
Mixed cellular casts: RBC/WBC WBC/RTE WBC/bacterial
Range of numbers/LPF
0/LPF
Glomerulonephritis Pyelonephritis
More than one Clumped RBCs, cell type included WBCs, and RTEs within each cast
Red blood cells (RBC)
Range of numbers/HPF
0–2 or 3/HPF
Damaged glomerular membrane Malignancy Trauma
No nucleus Biconcave disk
Yeast Oil droplets Air bubbles
White blood cells (WBC)
Range of numbers/HPF
0–5 to 8/HPF
Infection/Inflammation Cystitis Bacterial infection Urethritis Prostatitis
Cells possess granules Multilobed nucleus
Renal tubular epithelial cell
Squamous epithelial cell
Rare, few, moderate, many/HPF
Few/HPF
None
Largest cell If folded, may be found in urine mistaken for a Large irregular cast cytoplasm Distinct nucleus approximately the size of a red cell
ELEMENT
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TABLE 27-4 Mini Atlas of Urinary Sediment (continued)
ELEMENT
REPORTED AS:
NORMAL VALUE Rare/HPF
PATHOLOGICAL CONDITIONS Increased numbers could indicate: Viral infection Malignancy
DISTINCTIVE FEATURES Sphere-shaped Polyhedral Caudate (tail) Distinct nucleus
CAUSES OF IDENTIFICATION ERROR
Transitional epithelial cell
Rare, few, moderate, many/HPF
Sphere-shaped can resemble RTE
Renal epithelial cell
Rare, few, moderate, many/HPF
More than 2/HPF indicates tubular injury and the specimen should be sent for cytologic exam
Tubular injury Tissue destruction
Not totally round Sphere-shaped Columnar-shaped Granular casts Cuboidal Large nucleus
Bacteria
Rare, few, moderate, many/HPF
Rare to few due to contamination during collection method
Lower or upper UTI
Cocci or Bacilli shaped
Amorphous urates or phosphates
Yeast
Rare, few, moderate, many/HPF
Small amount may be present due to contamination
Diabetes Immunosuppressed patients Vaginal yeast infections
Small-oval Refractive May have a bud
RBCs
Trichomonas vaginalis (parasite)
Rare, few, moderate, many/HPF
None
Sexually transmitted Vaginal inflammation
Pear-shaped with WBCs whipping tail Darting movement
Mucus thread
Rare, few, moderate, many/HPF
Frequently present in the urine of females
None
Thread-like
Hyaline cast
Spermatozoa
According to lab protocol
May be found following intercourse or nocturnal emission
None
Oval head with long tail
None
Oval fat bodies
Average number/HPF
None
Nephrotic syndrome Diabetes mellitus Tubular necrosis
RTE that contains Starch and fat lipids crystals
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TABLE 27-4 Mini Atlas of Urinary Sediment (continued) NORMAL CRYSTALS FOUND IN ACID PH
CHARACTERISTIC COLOR AND SHAPE
Amorphous urates
Yellow-brown or brick dust Clumped
Specimens that have been refrigerated causing a pink sediment
Calcium oxalate
Colorless squares with “X” shape in center Resembles an “envelope”
Renal calculi Foods high in oxalic acid After ingesting tomatoes and asparagus
Uric acid
Yellow-brown Rhombic flat plate with four sides Rosettes
Gout Leukemia
NORMAL CRYTSTALS FOUND IN ALKALINE PH
CHARACTERISITIC COLOR AND SHAPE
Amorphous phosphates
Colorless
Specimens that have been refrigerated causing a white precipitate
Triple phosphate
Colorless Resemble “coffin lids”
Highly alkaline urine
Calcium carbonate
Colorless “Dog bone” or “dumbbell” shaped
No pathology
Ammonium biurate
Yellow-brown Spicules
Old specimens Ammonia produced by bacteria
SEEN IN:
SEEN IN:
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TABLE 27-4 Mini Atlas of Urinary Sediment (continued) ABNORMAL CRYSTALS
COLOR AND SHAPE
PATHOLOGY
Cystine
Colorless Thick or thin hexagon-shaped plates
Cystine reabsorption metabolic disorder Renal calculi
Tyrosine
Colorless to yellow Needles Clumps of rosettes
Severe liver disorders
Leucine
Yellow spheres with central circle and stripes
Severe liver disorders
Cholesterol
Colorless Rectangle with a notch in one or more corners
Lipiduria Nephrotic syndrome
ARTIFACTS IN URINE SEDIMENT: Artifacts can resemble pathologic elements and therefore can be difficult to differentiate from true pathologic elements. Starch Oil droplets Air bubbles
Starch
Pollen grains Fibers Fecal contamination
Another important factor to consider is the correlation of the reagent strip findings with the microscopic findings. For instance, if the reagent strip is positive for leukocytes, then white blood cells should be seen and reported during the microscopic exam. Another factor is the correlation of one chemistry result to another. A positive glucose almost always correlates with positive ketones, and a positive nitrite frequently correlates with white blood cells. Table 27-5 is a reagent strip/ microscopic correlation chart that illustrates the connection between reagent strip findings and the anticipated microscopic results.
Pollen grains
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C R I T I C A L T H I N K I NG CHALLENGE A dipstick analysis you performed on a urine specimen revealed a moderate amount of blood in the specimen. The physician performed the microscopic exam, but did not find any red blood cells present. 1. What could be the explanation for this?
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Important facts to remember when performing a urinalysis: ❖ Glove before assembling equipment. The outside of the reagent strip bottle and the outside of the specimen container could be contaminated with urine. ❖ The specimen should be in a clean, dry container. ❖ The first-morning specimen is the most concentrated and therefore the best specimen for testing. ❖ If possible, the specimen should not be tested during a female’s menses. ❖ The specimen must be refrigerated if not tested within one to two hours of collection and should be brought to room temperature prior to testing.
❖ Never store urine specimens in the same refrigerator with food items. ❖ Mix the specimen well before beginning the test. ❖ Do not allow excess urine to run from one reagent pad to the next. This can cause inaccurate readings. ❖ Proper timing is critical for accurate results. ❖ Do not touch a reagent strip that has been dipped in urine to the outside of the reagent strip bottle. ❖ Inform the physician that the sample is ready to read. Allowing the slide to sit for any length of time can cause the specimen to dry up.
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F IELD SM A RTS
TABLE 27-5 Urinalysis Reagent Strip/Microscopic Correlation Chart SUBSTANCE/RELATED TERM IF FOUND IN URINE
NORMAL VALUE
CLINICAL SIGNIFICANCE
Glucose/Glucosuria
Negative
Diabetes mellitus Pancreatitis Gestational diabetes Hyperthyroidism
+Ketones (in patients with diabetes)
False positive: Detergents Increased levels of ascorbic acid/ Vitamin C False negative: Increased specific gravity Increased ketones
Bilirubin/Bilirubinuria
Negative
Hepatitis Cirrhosis Bile duct obstruction
+Urobilinogen (in patients with liver disease)
False positive: Intestinal disorders False negative: Exposure to light Ascorbic acid Increased nitrites
Ketones/Ketonuria
Negative
Starvation Diabetic acidosis Vomiting Exercise
+Glucose (in patients with diabetes)
False positive: Certain medications (Levadopa) Red dyes Breakdown of bacteria Incorrect timing of reading
CORRELATION
CAUSES OF ERROR/ INTERFERENCE
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TABLE 27-5 Urinalysis Reagent Strip/Microscopic Correlation Chart (continued) SUBSTANCE/ RELATED TERM IF FOUND IN URINE
NORMAL VALUE
CLINICAL SIGNIFICANCE
Specific gravity (SG)
1.005–1.030
Measure of the kidneys’ concentrating ability ↑ in diabetes mellitus ↓ in diabetes insipidus
Blood: Hematuria Hemoglobinuria Myoglobinuria
Negative
Glomerulonephritis Calculi Trauma Severe burns Strenuous exercise Muscle wasting
RBCs present on microscopic exam unless the condition is hemoglobinuria, in which case the red cells have lysed and released hemoglobin + Protein
False positive: Menses False negative: Increased specific gravity with crenated RBCs Increased nitrites Captopril use Vitamin C use
pH 4.5–8.0 (7.0—Neutral) (Below 7.0—Acidic) (Above 7.0—Alkaline)
Metabolic/respiratory acid/base disorders Renal calculi UTI treatment Crystals
pH identification of crystals +Nitrites
Inaccurate readings: Allowing urine to run from one test pad to another
Protein/Proteinuria
Negative
Early renal disease Muscle injury Severe infection and inflammation Glomerular problems
+Blood +WBCs +Nitrites
False positive: Disinfectants Detergents Increased specific gravity False negative: Proteins other than albumin Dilute urines Fever
Urobilinogen/ Urobilinogenuria
0.1–1.0
Hemolytic diseases Hepatitis Cirrhosis Cancer of the liver
+Bilirubin (liver disease)
False positive: Certain diseases Highly pigmented urine False negative: Old specimen Formalin used as a preservative
CORRELATION
CAUSES OF ERROR/ INTERFERENCE Increased SG: Increased protein Decreased SG: pH below 6.5
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PROCEDURE 27-1 Instruct a Patient on a Clean-Catch Midstream Urine Collection Objective: To instruct a patient how to collect a clean-catch midstream urine specimen.
Equipment/Supplies: ❖ PPE ❖ Urine specimen cup with tight fitting lid
❖ Cleansing towelettes ❖ Patient’s chart
PROCEDURAL STEPS
RATIONALE
1. Wash your hands and apply gloves.
Gloves must be worn when handling the specimen after it is collected to protect against disease transmission.
2. Assemble the necessary equipment.
Assembling all necessary equipment keeps things organized and saves time.
3. Identify the patient using at least two identifiers, and identify yourself.
Identifying the patient ensures that you are instructing the proper person on specimen collection.
4. Take the patient to a private area near the restroom to explain the collection procedure.
The patient’s privacy must be maintained at all times according to HIPAA regulations.
5. Give the patient gloves (optional), towelettes, and a urine specimen cup with the patient’s name on it. Make sure the specimen cup has a lid.
Gloves may be offered to the patient to keep the hands clean during the collection. Towelettes are used for cleansing the genital area prior to collection, and the lid is placed on the specimen cup after collection.
6. Explain the collection process. Females: • Instruct the patient to spread the labia apart with one hand to expose the urinary meatus, then take one towelette and wipe down the right side of the meatus from front to back, then discard the towelette. • Instruct the patient to take a second towelette and wipe down the left side of the meatus from front to back and discard the towelette. • Instruct the patient to take the third towelette and wipe down the middle of the meatus from front to back and discard the towelette. Males: • Instruct the patient to retract the foreskin (if applicable) and cleanse the tip and the urethral opening, from the tip of the penis toward the ring of the glans, with two separate towelettes before beginning to collect the specimen.
The purpose of cleansing the area before collecting the specimen is to remove any epithelial cells and surface bacteria that could contaminate the specimen.
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RATIONALE
PROCEDURAL STEPS 7. Females and Males: Instruct the patient to keep the labia apart or the foreskin retracted, and begin to urinate into the toilet. Catch the middle portion of the urine in the specimen cup and finish urinating in the toilet.
Keeping the labia spread apart or the foreskin retracted will prevent contamination of the area that was just cleansed. If the patient were to collect the first portion of the urine flow, it could be contaminated with epithelial cells and bacteria that are in the urethra. Contamination may make the specimen difficult to read upon microscopic examination.
8. Instruct the patient to place the lid tightly on the specimen container and wipe the outside of the container with a paper towel.
A tight lid will prevent spills.
9. The patient should leave the sample in the designated area and wash hands.
Contaminated waste must be discarded in a biohazard container. Hands must be washed after removing gloves to prevent contamination.
10. The medical assistant should obtain the specimen and follow the provider’s orders. The collection must be documented in the patient’s chart for future reference.
11. Document the clean-catch order.
DOCUMENTATION EXAMPLE:
10-10-XX 10:30 a.m.
Instructed patient on collecting a clean-catch midstream urine sample per Dr. Samuals. Specimen sent to Qwest Laboratory for a complete urinalysis. Lilly Karnes, CMA (AAMA)
PROCEDURE 27-2 Perform a Physical and Chemical Urinalysis and Prepare a Microscopic Slide for the Provider Objective: To perform a physical and chemical urinalysis and prepare a slide of urinary sediment for microscopic examination.
Equipment/Supplies: ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖
Gloves PPE Urine specimen Urine control sample Centrifuge tubes Centrifuge Disposable pipettes Microscopic slides
❖ ❖ ❖ ❖ ❖ ❖ ❖
Cover slips Reagent strips Digital refractometer Lab report form Lab log sheet Biohazard container Patient’s chart
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PROCEDURAL STEPS 1. Wash your hands and apply appropriate PPE.
Urine is a body fluid, and PPE must be worn when handling a body fluid specimen.
2. Assemble the necessary equipment.
Having all equipment readily available saves time.
3. Gently mix the specimen.
The specimen must be well mixed to evenly distribute all components present.
4. Pour the specimen into a clear centrifuge tube (Figure 27-17). While holding the specimen in front of a light source, assess and record the color of the urine.
Viewing the specimen in front of a light source makes it easier to assess the true color.
5. Observe the transparency of the urine by holding a printed sheet of paper behind the specimen (Figure 27-18).
Observing printed material through the specimen makes it easier to determine the presence or degree of cloudiness.
6. Note any unusual odor, if present.
Odor is not routinely assessed, unless it is unusual.
7. Measure the specific gravity with either a digital refractometer (following the manufacturer’s instructions) or by the reagent strip method.
Both methods are waived by CLIA.
8. Dip the reagent strip in the urine specimen, or urine tube if urine is to be cultured, being certain to cover the entire strip with urine (Figure 27-19).
Dipping the strip into the original specimen can affect culture results. The entire strip must be covered with urine for a reaction to occur on all test pads.
9. After removing the strip from the cup, tilt it sideways on a paper towel to allow excess urine to be removed (Figure 27-20).
Excess urine can run down the strip, carrying the chemicals from one test pad to another and producing inaccurate results.
10. Hold the strip next to but not against the color chart on the bottle (Figure 27-21).
Holding the strip against the bottle will contaminate the outside of the container.
FIGURE 27-18 Assess the clarity of
FIGURE 27-19 Carefully dip the
the urine.
reagent strip into the well-mixed specimen. Note: Make sure all the reagent pads are covered completely by the urine.
FIGURE 27-20 Tilt the strip sideways and allow excess urine to drain onto a paper towel.
FIGURE 27-21 Compare the strip to the color chart on the container at the right time intervals.
FIGURE 27-17 Pour the urine specimen into a clear tube.
continues Copyright 2009 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
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RATIONALE
PROCEDURAL STEPS 11. Accurately time all readings and read the results.
Timing is critical to obtain accurate results.
12. Record all results on a report form and in the lab log, using a pen covered with a disposable plastic sheath. Follow office protocol for all positive results.
Results must be recorded immediately to ensure accuracy. The sheath is to keep the pen from becoming contaminated.
13. Centrifuge the urine specimen for five minutes at 2500 rpm.
Centrifugation concentrates all elements in the sediment at the bottom of the tube.
14. Carefully pour the supernatant off and mix the sediment well (Figure 27-22).
When pouring the supernatant, some of the sediment could become dislodged and be disposed of along with the liquid. Mixing the sediment well ensures good distribution of the elements present.
15. Place one drop of well-mixed sediment on a glass slide and place a cover slip over the drop of urine (Figure 27-23).
The cover slip spreads the drop of urine out, making it easier to examine.
16. Place the slide under the microscope and inform the physician that the specimen is ready to examine.
Microscopic examination of urine is not a CLIA waived test and must be performed by a physician.
17. Properly dispose of all equipment and specimens. 18. Remove gloves and wash your hands.
Hand must be washed both before and after wearing gloves.
19. Document the procedure.
DOCUMENTATION EXAMPLE:
11-08-XX 10:00 a.m.
Physical and Chemical UA per Dr. Leonard. Color: straw. Clarity: hazy. pH: 6.0. SG: 1.020. Nitrites: 1+. WBC: Mod. All other results negative. Lyn Collier, RMA
FIGURE 27-23 Gently place the (a)
(b)
FIGURE 27-22 (a) A button of sediment forms after centrifugation. (b) Gently pour off the supernatant, being careful not to dislodge the sediment button in the bottom of the tube.
cover slip over the drop of urine, making sure the drop spreads evenly.
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Chapter Summary A routine urinalysis can provide valuable information about many metabolic processes and other abnormalities occurring within the body. As the kidneys filter and cleanse the blood, substances such as bacteria, parasites, blood cells, casts, crystals, and metabolic by-products can be found in the urine upon examination. The medical assistant must be able to not only instruct the patient on proper specimen collection, but must also observe strict guidelines for the handling and preservation of the specimen. Accurate test results start with a properly collected and preserved specimen. The medical assistant must be able to accurately perform a physical and chemical urinalysis, perform quality control, and be able to identify factors that could interfere with the accuracy of test results.
FIELD APPLICATION CHALLENGE A female patient calls the office complaining of symptoms related to a UTI. The patient tells you that she has urinary frequency and pain upon urination. The patient also states that she is on her menstrual cycle. The provider’s schedule is full, so the provider asks you to instruct the patient to collect a clean-catch midstream sample and drop it off at the office to be tested. The specimen arrives, but is left at room temperature for over three hours.
2. Will the fact that the patient is on her menses affect the results of the urinalysis? 3. What changes could occur in a sample left at room temperature for three hours? 4. What action should be taken in order to obtain accurate results?
1. Will the test results on this specimen be accurate? Why or why not?
Chapter Assessment 1. Which part of a urinalysis gives information on the protein content of the urine? a. Physical b. Microscopic c. Volume d. Chemical 2. The pigment that gives urine its color is: a. urobilin. b. urochrome. c. amorphous. d. bilirubin. 3. Liver disorders may yield a positive reagent strip test for: a. blood. b. protein. c. bilirubin. d. nitrites.
4. A positive glucose reaction on the reagent strip would require further testing by which of the following methods? a. Ictotest b. SSA c. Acetest d. Clinitest 5. Which of the following would be considered abnormal if found in the urine? a. RBC casts b. 0–2 RBCs/hpf c. 15–20 WBCs/hpf d. Few calcium oxalate crystals 6. The presence of tyrosine crystals in the urine would be considered: a. abnormal. b. normal. c. suspicious. d. OK.
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7. The Ictotest is a confirmatory test for: a. acetone. b. ketones. c. protein. d. bilirubin. 8. A positive test for micro-albumin could be an early indicator of: a. diabetes. b. kidney disease. c. liver disease. d. hypertension.
Web Activities 1. Visit the Kidney Foundation’s Web site at http:// www.kidneyfoundation.com to search for information and programs available to patients with kidney disease. 2. Search the Centers for Disease Control and Prevention’s Web site at http://www.cdc.gov for current recommendations for specimen collection and handling.
CONNECTION Using your StudyWARE CD-ROM: ❖ Complete the Concentration activity for this chapter. ❖ Complete the Quiz for this chapter in Test Mode.
THE DVD LINK On your StudyWARE CD-ROM, go to the DVD Challenge for this chapter. View the DVD clip and respond to the following questions: 1. What did the medical assistant tell the patient he was to do with the first urine sample from day one? 2. What was Mr. Breech upset about in regards to preserving the specimen? 3. What other directions could the medical assistant have given that might have made the patient feel more comfortable?
C H A P T E R
Hematology and Coagulation Studies Chapter Outline Hemopoesis Blood Components Plasma Erythrocytes Leukocytes Thrombocytes Basic Hematology Studies The Complete Blood Count (CBC) Red Blood Cell Count White Blood Cell Count
Platelet Count Hemoglobin Hematocrit Differential Count Red Blood Cell Indicies Erythrocyte Sedimentation Rate (ESR) Automated Hematology Analyzers Coagulation Tests
Developmental Objectives After completing this chapter, you should be able to: 1. Correctly spell and define the essential terms. 2. Describe the process of hemopoesis. 3. List the cellular components found in blood and the function of each. 4. List the tests included in the CBC and the normal values for each individual test.
28 Essential Terms anisocytosis basophil complete blood count (CBC) differential count eosinophil erythrocyte erythrocyte sedimentation rate (ESR) hematocrit hemoglobin hemostasis leukocyte lymphocyte macrocyte microcyte monocyte morphology neutrophil normocyte plasma poikilocytosis serum thrombocyte
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KEY COMPETENCIES
CAAHEP
ABHES
Performing a Microhematocrit
III.C.3.b.3.c.ii III.C.3.b.1.d
VI.A.1.a.4.z VI.A.1.a.4.q
Preparing a Differential Blood Smear
III.C.3.b.3.c.ii III.C.3.b.1.d
VI.A.1.a.4.z VI.A.1.a.4.q
Performing an Erythrocyte Sedimentation Rate
III.C.3.b.3.c.ii III.C.3.b.1.d
VI.A.1.a.4.z VI.A.1.a.4.q
5. Discuss the function of hemoglobin. 6. Explain why the hematocrit would be increased during periods of dehydration. 7. Discuss the rationale for using mylar-wrapped glass capillary tubes or plastic tubes versus traditional glass capillary tubes. 8. List the different types of white blood cells found on a differential, their normal values, and reasons for an increase in each type. 9. Explain the importance of the red blood cell indicies. 10. Describe the two methods for determining the ESR.
Introduction Hematology is the study of blood and the blood-forming tissues with a primary focus on the formed elements found in the blood, which include red blood cells, white blood cells, and platelets suspended in a liquid called plasma. Plasma accounts for 50% to 60% of the total blood volume. The functions of blood include the transportation of both nutrients and waste products, carrying oxygen to the cells of the body, protecting the body against infection, and playing a vital role in the coagulation/clotting process. Hematologic tests can supply the provider with valuable information about a patient’s state of health. An abnormality in these studies may be the first sign that a more serious condition exists, prompting the provider to conduct additional tests.
HEMOPOEISIS The terms hemopoeisis and hematopoesis refer to the formation and development of blood cells, which primarily takes place in the bone marrow of the ribs, sternum, and pelvic bone. Initially, blood cells begin their development in the liver of the young fetus. As the fetus matures, the majority of cellular components are formed in the bone marrow. Lymphocytes, a particular type of white blood cell, are not only produced in the bone marrow, but in the lymph nodes and spleen as well. Blood cell formation and development is a continuous process that begins in the bone marrow with a single cell known as a stem cell. The stem cell begins as a nondifferentiated single cell that develops and matures while gradually taking on the characteristics of a specific cell type. When the stem cell matures, it is released into the peripheral circulation. Figure 28-1 shows the development and maturation of different blood cell types and their characteristic traits.
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FIGURE 28-1 The maturation of blood cells and platelets beginning from a single stem cell
BLOOD COMPONENTS The blood volume of the average adult is approximately five liters (L), or 10 to 12 units. Of the volume, 50% to 60% is composed of plasma, while the remaining portion consists of the formed cellular components.
Plasma Plasma, the liquid portion of the blood, consists of approximately 90% water with the remaining 10% consisting of electrolytes, hormones, carbohydrates, lipids, amino acids, protein, and antibodies. Tests to
measure the levels of these substances in the blood are usually conducted in the chemistry department of the laboratory. Coagulation proteins, known as clotting factors, are also found in the plasma. Two functions of plasma are the transportation of nutrients to the cells of the body and the transfer of waste products for elimination by the kidneys.
Erythrocytes Erythrocytes, or red blood cells (RBC), are the most plentiful cellular component found in the blood. They transport oxygen to the cells of the body and carry
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TOOL BOX
F IEL D S M A R T S Many students are confused about the difference between plasma and serum. Both are the liquid portion of the blood; however, plasma comes from whole blood and serum comes from clotted blood. Both contain the exact same constituents, the only difference is that one of the two contains clotting factors and the other doesn’t.
TOOL BOX
CR ITI C A L TH I N K I N G C H AL LEN G E Referring to the Field Smarts tool box above, which liquid contains the clotting factors: plasma or serum? Referring back to Chapter 26, which tubes (when centrifuged) provide the medical assistant with serum and which tubes provide the medical assistant with plasma?
carbon dioxide to the lungs to be exhaled. The biconcave shape of the red cells provides a surface area large enough for the oxygen and carbon dioxide exchange to take place and also allows for easy movement through the small blood vessels. Hemoglobin is a protein molecule attached to the red blood cells that contains an iron pigment that gives the red cells their color. Several different types of hemoglobin molecules exist along with genetic variants of these molecules. The genetic variants are responsible for different blood disorders such as sickle cell anemia. Hemoglobin is the part of the red cell responsible for transporting oxygen and carbon dioxide to and from the cells of the body. When hemoglobin binds with oxygen, it gives arterial blood its bright red color, while hemoglobin that has released oxygen into the tissues gives venous blood its dark red color. A mature erythrocyte remains functional in the blood stream for approximately 120 days. At the end of its lifespan, the cell is removed from circulation by the spleen and liver.
Leukocytes Five different types of leukocytes, or white blood cells (WBC), include neutrophils, eosinophils, basophils, lymphocytes, and monocytes. Leukocytes guard the body against infection by producing antibodies and functioning in the immune response. White blood cells move through the bloodstream to the site of an infection, where they perform various functions. Leukocytes engulf (eat) and remove pathogens from the body in a process known as phagocytosis. Each type of white blood cell has a very specific function; these functions will be discussed later in the chapter.
Thrombocytes Thrombocytes, or platelets, are actually cellular fragments of the megakaryocyte and are not considered complete cells. They function mainly in the process of hemostasis (stopping the flow of blood). Platelets stop bleeding by forming a plug in the damaged blood vessel wall and by releasing a chemical that participates in the coagulation cascade.
BASIC HEMATOLOGY STUDIES Hematologic tests are among the most common performed in a physician’s office laboratory (POL). The provider can obtain information about the health status of hematopoetic organs and related structures as well as particular disease processes occurring within the body. Complete blood count (CBC) results can assist the provider in monitoring the effectiveness of radiation and chemotherapy treatment and other hematological treatments. Cellular components are measured individually to determine the relative number present and the cell types are examined for their distinctive characteristics. For instance, a patient with a decreased red blood cell count is diagnosed with anemia. Since there are a number of different types of anemias, an evaluation of the red cell morphology (a study of the cell’s size, shape, and color) can help to determine the type and cause of the anemia. The provider can also determine whether an infection is viral or bacterial by evaluating the results of the white cell differential count. This test, usually performed as part of the CBC, determines the percentage of the different types of white blood cells present and examines their characteristics. Table 28-1 lists some of the blood disorders that may be detected by a simple hematology test.
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TABLE 28-1 Common Blood Disorders or Blood Terms Anemia
Caused by a decrease in the number of red blood cells or a deficiency in their function Several types of anemia exist and are classified by function and morphology of the red cells.
Aplastic anemia
Caused by bone marrow disorders that cause red cell production to be decreased or inhibited
Hemolytic anemia
Inherited or acquired disorder that causes destruction of the red cells
Iron deficiency anemia
Most common type of anemia, caused by a decrease in stored iron
Pernicious anemia
Caused by decreased oxygen-carrying capacity of the red cells
Sickle cell anemia
Inherited disorder causing an abnormality in the shape and hemoglobin-carrying capacity of the red cells
Erythrocytosis
An increase in the number of red blood cells
Leukemia
Usually marked by an abnormal increase in white blood cells; malignant disorder of the blood-forming tissues
Leukopenia/ Leukocytopenia
A decrease in the number of white blood cells
Leukocytosis
An increase in the number of white blood cells
Pancytopenia
A decrease in all blood cell types
Polycythemia
An increase in red cell production
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F IEL D S M A R T S Sickle cell anemia is an inherited disorder caused by the presence of an abnormal hemoglobin (hemoglobin S) in the blood. This abnormal hemoglobin becomes thickened when exposed to a decrease in oxygen, which in turn causes the red cells to be crescent, or sickle, shaped. The abnormal shape of the cells interferes with their movement through the capillaries, creating an obstruction that can cause pain in the area.
THE COMPLETE BLOOD COUNT (CBC) One of the most frequently ordered lab tests is the complete blood count (CBC). This group of tests supplies
the provider with a count of the cellular components, a percentage of the different types of white blood cells, the hemoglobin content of the red blood cells, and a listing of abnormal cells. CBC parameters can vary by facility, but usually include the following: ❖ ❖ ❖ ❖ ❖ ❖ ❖
Red blood cell count White blood cell count Platelet count or estimate Hemoglobin Hematocrit Differential RBC indices
Most tests included in the CBC can be performed by manual or automated methods. Manual methods are used when the analysis cannot be performed by automation due to instrumentation problems. Manual methods have many more sources of error than automated methods and take much more time to perform; they are therefore not used much in today’s laboratory.
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Currently, there are no waived CBC analyzers on the market. However, Cholestec, a leading manufacturer of point of care testing systems, recently announced a joint agreement with Boule Diagnostic International to manufacture a waived hematology system. Once that occurs, hematology testing will be able to be performed in labs with a certificate of waiver from CLIA.
Red Blood Cell Count The red blood cell count measures the number of RBCs present in 1 cubic millimeter (written as cu mm or mm3) of blood. The count supplies the provider with an estimate of the relative number of RBCs present in the patient’s total blood volume. This parameter is useful in evaluating different types of anemias as well as in determining other conditions such as dehydration. The RBC count is reported as the number of RBCs/cu mm of blood.
White Blood Cell Count The white blood cell count supplies the provider with information that can assist in the diagnosis and treatment of infectious processes and disease states. It can also aid in following the progress of a disease and the effectiveness of particular therapies and treatments. Often, as a disease becomes more advanced, the WBC count will increase proportionately. The white blood cell count measures the number of WBCs present in 1 cu mm of blood; results are reported as the number of WBCs/cu mm of blood. An increase in the number of white cells (leukocytosis) may be seen in acute infections such as mononucleosis, chicken pox, and appendicitis, as well as some leukemias. A decrease in the white cell count (leukopenia) can be indicative of a viral infection or can be the result of chemotherapy and radiation.
Platelet Count Platelets are cells active in blood clotting. Manual platelet counts may still be performed in some laboratories; however, the count is usually calculated by an automated instrument and is reported as the number of platelets/cu mm of blood. The platelet count is important when evaluating patients for the presence of clotting disorders. A decrease in the number of platelets can place a patient at risk for bruising and uncontrolled bleeding. Platelet disorders can be either inherited or acquired.
Hemoglobin The hemoglobin determination is an indirect measurement of the oxygen-carrying capacity of the red blood cells. It aids in determining blood loss and anemias and is also valuable for monitoring other conditions such as dehydration. The hemoglobin level can also provide information concerning the effectiveness of blood transfusions. An increase in the hemoglobin level can occur in conditions like COPD (chronic obstructive pulmonary
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C R I T I C A L T H I N K I NG CHALLENGE Think about the function of hemoglobin on the red cells. 1. Why might a patient’s hemoglobin level be increased in a condition like COPD?
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FI E L D S M A R T S TOOL BOX
CR ITI C A L TH I N K I N G C H AL LEN G E You receive a patient’s CBC report that reveals a highly elevated red blood cell count. 1. What are some possible causes? 2. What should you do with the results?
Because hemoglobin carries oxygen to the cells of the body, it is common for patients to experience both fatigue and shortness of breath when their hemoglobin levels plummet. Be certain to alert the provider prior to examination if the patient is experiencing these symptoms. The provider may want testing performed immediately to determine if a low hemoglobin level is the reason for the patient’s symptoms.
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disease), CHF (congestive heart failure), and polycythemia, while a decrease can occur with anemia and severe blood loss. A hemoglobin determination can be easily performed using an automated device such as the Hemocue hemoglobin analyzer (Figure 28-2). The Hemocue is waived by CLIA and, therefore, ideal for use in the POL. Several other manufacturers offer analyzers that are also CLIA waived. By performing this analysis in-house, the provider has the advantage of testing the patient and receiving results while the patient waits. Treatment can be implemented much sooner than if it was necessary to wait for results to be received from an outside laboratory. The hemoglobin determination results are reported as grams of hemoglobin per deciliter (g/dL).
Hematocrit The hematocrit, also a CLIA waived test, is a quick and easy method for determining the volume of packed red blood cells in a given volume of blood. Hematocrit is reported as a percentage (for example, a hematocrit reported as 48% means that 48% of the total blood volume is made up of red blood cells). The hematocrit is performed by centrifuging a small sample of whole blood in a petite narrow tube called a capillary tube. The test is often referred to as a microhematocrit test because of the size of the tubes. Either capillary or venous blood may be used for this determination. Until recently, glass capillary tubes were used to perform the testing, however reports of accidental injuries due to tube breakage while sealing the tube prompted safety concerns. New safety capillary tubes made of plastic, or glass tubes wrapped in mylar, add
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FI E L D S M A R T S Separation Technology Inc, a manufacturer of microhematocrit equipment, states that leaving the cap off of a self-sealing capillary tube bottle for extended periods of time may result in impaired capillary action. Moist air can become trapped in the tube, which can affect the tube’s vacuum. Replacing the cap and allowing the tubes to sit for 24 hours should solve the problem.
strength and durability to capillary tubes and result in less breakage and fewer injuries. Plain or heparinized capillary tubes are available for use. The heparinized tubes must be used when collecting blood from a capillary puncture to prevent the sample from clotting prior to testing. Figure 28-3 shows some examples of safety capillary tubes. The tube fills by capillary action, a force that draws a thick liquid, such as blood, into a narrow tube. The tube is held horizontally while filling, and the end of the tube is placed into a well-rounded drop of blood. Once the tube is approximately three-fourths full, a gloved finger is placed over the wet end of the tube, and the dry end of the tube is pushed into sealing clay to prevent the blood from running out of the tube. Self-
FIGURE 28-2 A Hemocue automated hemoglobin analyzer
Image not available due to copyright restrictions
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Capillary tube
Plasma
Buffy coat
Red blood cells
FIGURE 28-4 A microhematocrit centrifuge and crit reader Sealing clay
sealing capillary tubes and plastic sealing caps are now preferred for safer sealing of the tubes. Filled capillary tubes are placed in the microhematocrit centrifuge (Figure 28-4) with the sealed end toward the gasket or outside of the unit, and spun for two to five minutes. When centrifuged, the cellular components of the blood are separated into two layers with the red blood cells at the bottom, the white blood cells and platelets in the middle (buffy coat), and the plasma on top. Figure 28-5 illustrates the separation
FIGURE 28-5 An illustration of a hematocrit tube after centrifugation. Note the separation into distinct layers.
of the cellular components after centrifugation. The spun hematocrit tubes are placed on a reading device and the percentage of red blood cells is determined. Two tubes are filled, centrifuged, and read, and the readings are averaged to determine the hematocrit. The two readings must agree within 2% or the test must be repeated. Procedure 28-1 lists the necessary steps for performing a spun microhematocrit.
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F IEL D S M A R T S Correlation of laboratory results is essential to ensure that tests have been performed accurately. A general rule of thumb is that the hematocrit should be approximately three times the result of the hemoglobin (for example, a sample with 12.5 g/dL of hemoglobin should have a hematocrit result of approximately 36% to 37%). If this rule does not hold true (for example, 12.5 g/dL of hemoglobin and a hematocrit of 50%), the test should be repeated.
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C R I T I C A L T H I N K I NG CHALLENGE You perform a microhematocrit and the provider is waiting for the results. One tube reads 34% and the other tube reads 30%. 1. Would this test be considered accurate? Why or why not? 2. What should be your next course of action?
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Differential Count The white blood cell differential count is a valuable tool used to assess many different patient conditions. The differential can provide information for diagnosing and treating anemias and leukemias, as well as differentiate between a viral and bacterial infection. The formed elements of the blood (RBCs, WBCs, and platelets) can be observed under the microscope and identified according to their characteristics. Performance of the differential requires a trained eye and, therefore, is not considered to be a waived test under CLIA ’88 guidelines. This test is usually not performed in the POL. Instead, the medical assistant may prepare the blood smears from a fresh specimen and place them in a protective covering to be sent to the lab for testing. Staining methods will be discussed later.
Slide Preparation A properly prepared blood smear is required in order to perform an accurate differential blood cell count. Slides must be clean and free from grease, fingerprints, and dust. It is important when handling the slides to pick them up by the ends to avoid smudging the area used for the blood smear. Slides with frosted ends are preferred for easy labeling.
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The specimen of choice for a blood smear is capillary blood. The blood can be applied directly to the slide from the puncture site or collected in heparinized capillary tubes and then applied to the slide. Venous blood may also be used as long as the anticoagulant is EDTA. Other types of anticoagulants can distort the appearance of the blood cells, making them difficult to identify. The most common method for preparing a blood smear is the “two-slide” or “wedge” method. Procedure 28-2 provides the necessary steps to prepare a differential blood smear by this method. A properly prepared smear will cover approximately two-thirds to three-fourths of the slide. It will be thickest at the end where the blood was initially applied and gradually thin out to a “feathered” edge. The smear should be smooth with no holes or ridges. The differential count is performed in the “thinner” area of the smear where cells do not overlap. Table 28-2 lists possible sources of error and causes for each when preparing a blood smear. Refer to Figure 28-6 for examples of improperly prepared blood smears and Procedure 28-2 for a properly prepared slide. Once the smear has been made, it should be allowed to air dry and be stained within one hour or preserved by immersing in methanol for 30 to 60 seconds and
TABLE 28-2 Sources of Error in Blood Smear Preparation ERROR
POSSIBLE CAUSE
Too long or too thin
Spreader slide angle too low Inadequate (too small) drop of blood Incorrect spreading speed
Too short or too thick
Spreader slide angle too high Drop of blood too large Incorrect spreading speed
Waves or ridges
Hesitation while pushing spreader slide Variable pressure on spreader slide
Holes in smear
Dirty slide Edge of spreader slide not clean
Abnormal cell morphology/artifacts
Improper drying of smear High humidity Smear not fixed within appropriate time limit
Uneven cell distribution
Spreader slide with uneven edges Edge of spreader slide not clean Spreading of blood delayed Variable pressure on spreader slide
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The two most common stains used are Wright’s stain and Giemsa stain. Several staining methods are available from different manufacturers: ❖ One method uses three components: a fixative (to allow cells to retain the color produced by the dye), a red dye, and a blue dye. ❖ Another method uses a mixture of methylene blue, eosin, and a fixative. ❖ A third method uses an automatic staining machine. Medical laboratories that perform a large volume of testing will usually use this type of instrument. This device mechanically places the slides in the different stains and rinses them for the prescribed amount of time. This automatic process produces evenly stained slides of good quality.
Counting the Differential FIGURE 28-6 Improperly prepared differential blood smears
allowed to air dry. Methanol prevents the blood cells from changing or deteriorating on an unstained smear. Once the blood smear has been “fixed,” it can be stained at a later time.
Staining the Slide Staining the slide colorizes the blood cells, allowing them to be visible and more easily identified. The most common stains used are polychromatic stains that contain a basic dye (methylene blue) that stains cells a blue to purple color and an acid dye (eosin) that stains cells a pink to red-orange color. Certain cell structures will attract the basic dye while others will attract the acid dye. A properly stained slide will have a “pinkish” color when observed with the naked eye.
The differential cell count involves counting 100 white blood cells on a stained blood smear to determine the relative percentage of each type of cell present. The cells are evaluated and examined for their size, shape, color, and nuclear and cytoplasmic characteristics. The nucleus of the white blood cell should be examined for size, color, and structure. The cytoplasm should be observed for color, amount, and the presence or absence of granules. A drop of immersion oil is placed on the slide and the slide is placed on the microscope stage. The differential count is performed using the oil immersion objective for optimum magnification. Bright light is
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F IEL D S M A R T S When handling and preparing blood smears, observe strict Universal Precautions: ❖ Wear gloves and other PPE such as a mask, goggles, and a waterproof gown. ❖ Handle glass slides with care to prevent accidental breakage and possible cuts. ❖ Methanol is poisonous—handle with care. Avoid inhaling fumes and contact with skin.
Neutrophils, eosinophils, and basophils all received their names based on what happens during the staining process. The medical suffix -phil means an attraction to something. Eosionophils received their name because of their attraction to the eosin dye during the staining process; thus, their granules are orange-red. Basophils received their name because of their attraction to the basic dye, or methylene blue stain, causing their granules to be a purplish-black. Neutrophils received their name because they pick up a combination of both dyes, which provides a neutral color or pink to purple granules.
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also used for viewing cell characteristics. Cells in the counting area should just touch each other, and should not be piled or stacked on top of one another. The slide should be moved in a zig-zag or serpentine pattern to eliminate the possibility of counting the same cell twice. Each white cell is observed and identified according to the criteria in Table 28-3. After counting 100 white blood cells, the red blood cells are observed for their morphology. A difference
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seen in the size of the red blood cells is known as anisocytosis, while a difference in the shape of the red blood cells is known as poikilocytosis. Abnormal red cell morphology can be indicative of many different hematologic conditions. A normal red blood cell will have a biconcave shape, stain a pinkish color, and will have no nucleus. Red cells can either be normocytic (from normocyte, meaning of normal size), microcytic (from microcyte,
TABLE 28-3 Criteria for White Blood Cell Identification CYTOPLASMIC GRANULES
NUCLEAR CHARACTERISTICS
CYTOPLASMIC CHARACTERISTICS
Pinkish-purple fine granules
Lobed nucleus with two to five lobes and coarse structure
Pale pink-lavender color Large amount of cytoplasm
Neutrophil
Pinkish-purple fine granules
U-shaped
Pale pink-lavender color Large amount of cytoplasm
Band or stab (immature neutrophil)
Coarse orange-red granules
Two lobed
Pale pink-tan color Large amount of cytoplasm
Eosinophil
Coarse purple-black granules
Segmented
Pale pink-tan color Large amount of cytoplasm
Basophil
None
Round to oval shaped
Light blue color Small amount of cytoplasm surrounding the nucleus
Lymphocyte
None
Large, irregularly shaped
Large amount of grayishblue cytoplasm Vacuoles (holes) present in the cytoplasm
Monocyte
CELL TYPE
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(a) (c)
(d)
(b)
FIGURE 28-7 (a) A normal-sized red blood cell; (b) a microcyte; (c) a macrocyte; (d) a platelet
meaning smaller than normal), or macrocytic (from macrocyte, meaning larger than normal), as shown in Figure 28-7. The center of a normal red cell is thin and will not pick up as much color as the rest of the cell, creating a pale area described as a “central pallor.” The hemoglobin is contained in the pink area of the cell. If the central pallor is large, this means that the hemoglobin content of the red cell is decreased, alerting the provider that an abnormal condition exists. The biconcave shape of the red cell allows it to easily perform the function of carrying oxygen to the cells and tissues of the body and carbon dioxide away from the cells and tissues of the body. Red cells that are shaped differently cannot perform this vital function and are found in different anemias and blood dyscrasias (hematologic diseases). The last portion of the differential consists of examining the platelets, which appear as small purple fragments on the stained smear (see Figure 28-7). A platelet
estimate can be performed by counting the number of platelets in several microscopic fields and performing a mathematical calculation. Differentials are now performed in most large laboratories by automation. Analyzers sort cells by size and separate them into five classifications. Abnormal cells found on a differential are usually flagged by the automated instrument and a manual differential count is performed for specific observation of the cells. While the medical assistant typically will not perform a differential, being familiar with terms used to describe the results, and normal values and conditions that can affect the results, will assist the medical assistant with priority tasking and in providing education to the patient.
Red Blood Cell Indices The final component of the CBC is a group of tests that provides complete information about the red blood cells. The group of tests is known as the red blood cell indices. The indices are calculated using the values of the red blood cell count, the hemoglobin, and the hematocrit. The RBC indices are valuable in diagnosing, evaluating, and treating different types of anemias. The RBC indices include: ❖ Mean corpuscular volume (MCV) ❖ Mean corpuscular hemoglobin (MCH) ❖ Mean corpuscular hemoglobin concentration (MCHC) Table 28-4 includes information about each of the indices, including reference ranges, what the index is actually measuring, and possible reasons for increased or decreased values. Refer to Table 28-5 for information about all tests included in the CBC.
TABLE 28-4 RBC Indices REFERENCE RANGE
CAUSES FOR ABNORMAL VALUES
Volume of the average red blood cell in a given sample of blood
80–100 fL
High MCV: macrocytes Low MCV: microcytes
MCH
Estimation of the average weight of hemoglobin in a single red blood cell
27–33 pg
This test is not useful in classifying anemias because the hematocrit value is not used to calculate the results.
MCHC
Concentration of hemoglobin in the red blood cells in relation to their size and volume
32–37 g/dL
Low MCHC: hypochromia
TEST
MEASUREMENT
MCV
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TABLE 28-5 Tests Included in the Complete Blood Count REFERENCE RANGE*
TEST
ABBREVIATION
ABNORMAL VALUES SEEN IN:
Hematocrit
Hct
Males: 42–52% Females: 36–45% Neonates: 44–64%
High Hct results seen in: • Polycythemia • Vomiting • Diarrhea • Dehydration • Hyperglycemia
Hemoglobin
Hgb
Males: 13–18 g/dL Females: 12–16 g/dL Neonates: 15–20 g/dL
High Hgb results seen in: • COPD • CHF • Polycythemia Low Hgb results seen in: • Anemia • Blood loss • Leukemia
Red blood cell count
RBC count
Males: 4.5–6.0 million/cu mm Females: 4.0–5.5 million/cu mm Neonates: 4.0–6.6 million/cu mm
High RBC count seen in: • Polycythemia • Dehydration • Pulmonary fibrosis Low RBC count seen in: • Anemias • Leukemia
White blood cell count
WBC count
Adults: 4,500–11,000/cu mm Neonates: 9,000–25,000/cu mm
High WBC count seen in: • Acute infections • Appendicitis • Mononucleosis • Meningitis
Low WBC count seen in: • Viral infections • Chemotherapy • Radiation therapy
Low, seen in: • Viral infections • Humoral diseases • Chemotherapy
Low Hct results seen in: • Anemia • Hemorrhage • Pregnancy
Differential cell count Neutrophils
Segs
50–65%
High, seen in: • Bacterial infections • Parasitic infections • Liver disease
Bands
Stabs Juvs
0–7%
High, seen in: • Most infectious diseases • Some leukemias
Eosinophils
Eos
1–3%
High, seen in: • Allergic reactions • Parasitic infections • Lung and bone cancer
Basophils
Basos
0–1%
High, seen in: • Leukemia • Hemolytic anemia • Chronic inflammations
Lymphocytes
Lymphs
25–40%
High, seen in: • Viral infections • Carcinoma • Hematopoetic disorders
Low, seen in: • HIV infection • Myelocytic leukemia • Hodgkin’s disease
Monocytes
Monos
3–9%
High, seen in: • Certain bacterial infections
Low, seen in: • Chemotherapy
Low, seen in: • Infectious mononucleosis • CHF • Aplastic anemia
*Unless otherwise noted, all reference ranges are for adults. Please note: Reference ranges listed were compiled from several different sources. Laboratory reference values may differ from one lab to another according to test methodology and each laboratory’s own “normal patient population.”
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ERYTHROCYTE SEDIMENTATION RATE (ESR) The erythrocyte sedimentation rate (ESR), or sed rate, is a test that is easily performed in the POL. The principle of the ESR is to determine how far the red blood cells fall in a one-hour time frame in a given volume of whole blood. The ESR is not specific for one particular disease, but is used as an indicator of the presence of inflammation and tissue destruction. It is also used to follow treatment of certain conditions. Two manual methods are commonly used to perform the ESR: the Wintrobe method and the Westergren method. In both, wellmixed anticoagulated blood is placed in a calibrated tube and allowed to stand for one hour. The Wintrobe method uses a Wintrobe tube, which holds 1 mL of blood and has graduated markings from 0 to 100 mm. The tube is filled with well-mixed anticoagulated blood to the “zero” line and placed in a rack for one hour. After one hour, the distance the red blood cells have fallen is read and recorded as the ESR.
FIGURE 28-8 A Wintrobe sedimentation tube. Magnification shows an 8 mm/h ESR reading.
0
10
0
9
2
8
3
7
4
6
5
5
6
4
7
3
8
2
9
1
Blood
Distance erythrocytes have fallen
1
1. Timing is critical. The test must be timed for precisely one hour. 2. The tube must remain undisturbed in a vertical position for the entire hour. 3. The tube rack should be placed on a counter or table that is free of vibrations. 4. The sed rate tubes must not be placed in direct sunlight or draft. 5. The test should be performed at room temperature on well-mixed blood. 6. The test should be performed within two hours of specimen collection. Table 28-6 lists ESR normal values for both methods and Table 28-7 lists possible causes for both increased and decreased sed rate results.
10
Plasma
1
The results are recorded in mm/h. Figure 28-8 shows a magnification of the tube and its markings. The Westergren method requires blood to be mixed with a sodium citrate solution before filling the sed rate tube. The Sediplast system (Figure 28-9) is commonly used in the POL. It is a closed, self-filling system that protects medical personnel from possible exposure. Procedure 28-3 lists the steps necessary to perform the Sediplast method. General guidelines to follow when performing an ESR by either method include the following:
9
FIGURE 28-9 The Sediplast ESR system
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TABLE 28-6 ESR Normal Values GENDER
WINTROBE METHOD
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Males: <50 years of age >50 years of age
0–9 mm/h
0–15 mm/h 0–20 mm/h
Females: <50 years of age >50 years of age
0–20 mm/h
0–20 mm/h 0–30 mm/h
TABLE 28-7 Factors and Conditions Affecting the ESR
E M R A P P L I C AT I O N Many EMR programs are able to graph lab data. This is particularly helpful when viewing CBC results. The medical assistant can go into the lab files and click on CBC results. The medical assistant can then click on the graphing function and insert the dates that are to be included in the table. Once the medical assistant finishes inserting the dates, the appropriate tab can be selected to display the data. The results will now be displayed in a graphing format, which can be printed, faxed, or sent to other specialists that are caring for the patient.
FACTORS THAT CAN INCREASE THE ESR Plasma proteins that cause RBCs to stick together and fall faster Macrocytosis Pregnancy Anemia Cancer Inflammatory diseases like rheumatoid arthritis Acute and chronic infections
of practice. As stated previously, once the new waived analyzers are available, the medical assistant will be able to perform an automated CBC. An automated analyzer is fast, accurate, and simple to use. Many are equipped with printers that produce a hard copy of the results immediately. Some analyzers are also equipped to store quality control data. Hematology analyzers are available that can perform one or two tests or a complete blood count including RBC indices.
Multiple myeloma
FACTORS THAT CAN DECREASE THE ESR Sickle cell anemia Spherocytosis Polycythemia Microcytosis Irregularly shaped cells that do not stick together easily and fall more slowly
AUTOMATED HEMATOLOGY ANALYZERS Hematology tests performed in the POL will usually be performed using an automated instrument; however, as stated above, these analyzers are not CLIA waived and are therefore outside a medical assistant’s scope
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P A T I E N T P E R S P E CT IV E Being told you have cancer is very distressing, but it is even more agonizing when you can’t get anyone from your family physician’s office to send your CBC results to your oncologist. My chemotherapy cannot be started unless those results are available. Put yourself in my place: Take the time to ease my mind by making certain that requests are processed in a timely manner. Take a moment to call me and let me know that the results have been sent to my oncologist. Following these steps will allow me to concentrate on getting better instead of worrying if the test results will arrive before I do.
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COAGULATION TESTS Coagulation tests are sometimes performed in the hematology department of the laboratory or may be performed in a separate department in a larger laboratory. With the development of small handheld instruments, testing can now be performed in the POL. These tests are performed to diagnose abnormal bleeding disorders and to monitor patients on anticoagulant therapy. A common coagulation test is known as prothrombin time, or PT level. Another value that is reported with a PT result is referred to as “international normalized ratio,” or INR ratio. This ratio compares the results of prothrombin times amongst laboratories that use different test methodologies. By using this standardized system, it is easier to ensure both consistent results from one lab to another and the continuity of anticoagulant therapy. In some cases, only the INR is reported. Patients taking anticoagulants such as heparin or Coumadin will have their blood drawn at varying intervals to see how they are responding to anticoagulation threapy. Examples of patients on anticoagulant therapy include patients with a history of deep vein thrombosis (DVT), stroke (CVA), or myocardial infarction (MI, also known as a heart attack). Approximately 12 blood proteins, known as clotting factors, are needed to coagulate the blood and stop bleeding. Prothrombin, or Factor II, is one of the clotting factors produced by the body in the liver. The synthesis of prothrombin is dependent on adequate amounts of vitamin K. The prothrombin test is a valuable coagulation test, as it detects the presence and activity of five of the clotting factors and is used to determine how long it takes the blood to clot. Because prothrombin is produced by the liver, the prothrombin time can also be used to screen for vitamin K deficiency and liver function. Increased PTs are found in liver disease, depression of the bone marrow, cancer, and collagen disease. Decreased PTs may be seen in pulmonary embolism, multiple myeloma, myocardial infarction, and thrombophlebitis. A PT can now be quickly and easily performed in the POL with any of the several CLIA-waived instruments available on the market (Figure 28-10). These analyzers give the provider PT results in one minute using only a small amount of blood from a finger stick. By performing this test in-office, the physician may counsel the patient and make medication adjustments immediately.
(a) (b)
FIGURE 28-10 Small point-of-care coagulation analyzers: (a) HEMOCHRON Signature Elite; (b) ProTime (Photo courtesy of ITC, Edison, NJ.)
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C R I T I C A L T H I N K I NG CHALLENGE Why is it so important to ask patients on blood thinners about changes in dietary history, especially OTC vitamin and mineral therapy?
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FI E L D S M A R T S Patients who are on anticoagulant therapy commonly include those that have a history of deep vein thrombosis (DVT), myocardial infarction (heart attack), and stroke. These patients will usually be sent home from the hospital with a prescription for Coumadin or the generic warfarin sodium (both anticoagulants). Careful monitoring of these patients is essential, especially during the initiation stage of therapy. Patients that have a low PT and INR are in danger of developing a new clot, while patients that have an increased PT and INR are in danger of internal bleeding. Never allow the results of these tests to just sit on your desk. Alert the physician right away when results are abnormal and immediately follow up with the patient on any changes in medication orders.
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PROCEDURE 28-1 Perform a Microhematocrit Objective: Properly perform and determine the microhematocrit value by centrifuging a sample of blood in a capillary tube to separate the cellular components from the plasma.
Equipment/Supplies: ❖ ❖ ❖ ❖ ❖ ❖
Gloves Capillary tubes (plain) Sealing clay or sealing caps Microhematocrit centrifuge Microhematocrit reader EDTA blood sample
PROCEDURAL STEPS
❖ ❖ ❖ ❖
Tissue wipes Sharps container Biohazard container Patient’s chart
RATIONALE
1. Wash your hands and apply PPE.
Hands must be washed before and after each procedure and PPE, especially gloves, must be worn when handling any body fluid specimens.
2. Assemble the equipment and supplies.
Having the supplies ready to go will help the procedure efficiency.
3. Identify the patient using two identifiers, identify yourself, and explain the procedure.
Performing the testing on the wrong patient can result in serious consequences.
4. Perform a capillary puncture and wipe away the first drop of blood.
The first drop of blood could be contaminated with alcohol or diluted with tissue fluid, which will produce inaccurate results.
5. Hold a heparinized capillary tube to the second drop of blood without touching the skin. • Allow the capillary tube to fill three-fourths full. • After filling the tube to the appropriate level, wipe the outside of the tube with a tissue to remove excess blood. • Seal the end of tube with clay or a sealing cap (Figure 28-11). • Repeat the procedure with a second tube. • Apply a bandage to the patient's finger.
Heparinized capillary tubes must be used to prevent the blood from clotting. • The tube should be filled three-fourths full for easier reading. • Cleaning the outside of the tube prevents contaminating the centrifuge. • Tubes must be sealed or the blood sample will spin out of the tube.
6. Place tubes in the centrifuge directly opposite each other with the sealed ends pointed outward and pushed against the gasket (Figure 28-12).
The centrifuge must be balanced with equal weight to avoid tube breakage, and the clay must point outward to avoid losing the specimen during centrifugation.
7. Securely fasten both centrifuge lids.
This prevents breakage of the tubes.
FIGURE 28-11 Gently press the end of the capillary tube into the sealing clay.
FIGURE 28-12 Place tubes across from one another to balance the centrifuge.
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PROCEDURAL STEPS
RATIONALE
8. Set the timer for five minutes and adjust the speed if needed.
Proper timing and speed ensures accurate results.
9. Allow the centrifuge to stop completely before opening both lids.
Stopping the centrifuge manually can dislodge packed cells and cause injury to the medical assistant.
10. Remove both tubes, place them on the reader, and follow directions to determine the value.
Both tubes must be read to ensure test accuracy.
11. Average the results of both tubes.
Results must agree within 2%; if not, the test should be performed again.
12. Record the results as a percentage.
The hematocrit value is reported as percent of red blood cells in that volume of blood.
13. Properly dispose of the equipment.
Capillary tubes must be placed in a sharps container.
14. Remove PPE and wash your hands.
Washing hands reduces risk of cross-contamination.
15. Document the procedure.
All procedures must be correctly documented in the patient’s chart and the laboratory log to confirm the tests were performed.
DOCUMENTATION EXAMPLE:
11-08-XX 11:00 a.m.
Microhematocrit per Dr. Leonard. Result: 48% Ken Hardings, CMA (AAMA)
PROCEDURE 28-2 Prepare a Differential Blood Smear Objective: To properly prepare a blood smear on a slide, using well-mixed anticoagulated blood for the purpose of viewing the cellular components microscopically.
Equipment/Supplies: ❖ ❖ ❖ ❖ ❖ ❖
Gloves PPE EDTA blood sample (fresh) Paper towels Capillary tubes (plain) Microscopic slides with frosted ends
PROCEDURAL STEPS 1. Assemble the equipment and label the frosted end of the slide in pencil with the patient’s name and date.
❖ Sharps container ❖ Biohazard container RATIONALE Slides should be labeled before spreading to avoid identification error.
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PROCEDURAL STEPS 2. Wash your hands and apply PPE.
There is always the potential of splatter when working with tubes of blood.
3. Using a well-mixed EDTA anticoagulated sample, fill a capillary tube with blood, and place a drop of blood on the clean slide (Figure 28-13).
Anticoagulated blood must be used for blood smears to prevent cell distortion and clotting on the slide.
4. Place a clean spreader slide in front of the drop of blood at a 30° to 35° angle (Figure 28-14).
An angle greater than 30° to 35° will create a short, thick smear and an angle less than 30° to 35° will create a long, thin smear.
5. Pull the spreader slide back into the drop of blood, allowing the drop to spread approximately three-fourths of the width of the spreader slide (Figure 28-15).
Not allowing the drop to spread far enough will create a narrow smear.
6. Push the spreader slide forward with a smooth, quick motion (Figure 28-16).
Hesitation can cause ridges in the smear.
7. Repeat the procedure until two acceptable smears are obtained and properly dispose of the spreader slide in the sharps container.
Always make two smears so there is a backup slide.
8. Allow the smear to air dry.
Do not blow on the slide to dry it. Drying too quickly can cause holes to develop in the slide and can distort the cells on the smear.
9. Fix the slide with methanol if the smear will not be stained within one hour.
Failure to stain the smear within the one-hour time limit can cause cell distortion.
10. Place the slides in a protective covering for transport to the laboratory.
Slides must be protected against breakage and damage during transport.
11. Remove PPE and wash your hands, and dispose of biohazardous wastes.
Hands must be washed after removing gloves to avoid cross-contamination.
FIGURE 28-13 Place a drop
FIGURE 28-14 Place the
of blood on the slide near the frosted end.
edge of the spreader slide in front of the drop of blood.
FIGURE 28-15 Pull the spreader slide back into the drop of blood and allow the drop to spread across the slide.
FIGURE 28-16 Push the spreader slide forward with a quick, smooth motion. Do not lift up on the spreader.
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PROCEDURE 28-3 Perform an Erythrocyte Sedimentation Rate Objective: To accurately determine the erythrocyte sedimentation rate by the Sediplast (Westergren) method.
Equipment/Supplies: ❖ ❖ ❖ ❖ ❖
Gloves EDTA blood sample Sediplast kit and rack Timer Sharps container
PROCEDURAL STEPS 1. Wash your hands and apply PPE.
❖ Biohazard waste container ❖ Patient’s chart RATIONALE PPE reduces the risks of contamination during the procedure.
2. Assemble the equipment. 3. Mix the blood well for two minutes.
The blood must be well mixed to ensure that all components have been evenly distributed.
4. Remove the stopper from the sedivial and fill with 0.8 mL of blood to the indicated mark. Replace the stopper and mix the sodium citrate and blood well (Figure 28-17).
The correct amount of blood must be used and blood must be well mixed with sodium citrate solution to ensure correct dilution and distribution of cells.
5. Place the sedivial in the Sediplast rack and place the rack on a level surface.
The rack must remain level for accurate results.
6. Insert the Sediplast tube through the stopper using a twisting motion while pushing down until tube rests on the bottom of the vial and the blood reaches the zero line (Figure 28-18).
Proper filling of the tube ensures accurate results.
7. Set the timer for one hour.
Precise timing is critical to accurate results.
8. Read the results of the ESR at exactly one hour.
Reading results too early or too late will produce erroneous results.
9. Clean the work area and properly dispose of used equipment in biohazardous trash and the tube of blood in the sharps container.
Used equipment must be disposed of properly.
FIGURE 28-17 Fill the sedivial to the proper level, seal with the lid, and mix well.
FIGURE 28-18 Push the Sediplast tube into the sedivial with a firm, twisting motion until the tube fills to the zero line.
10. Remove gloves and wash your hands.
Hands must be washed following any procedure.
11. Record the results in the patient’s chart and the laboratory log.
Recording the results verifies the procedure was completed.
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DOCUMENTATION EXAMPLE:
02-24-XX 2:00 p.m.
Performed ESR per Dr. Karnes. Results: 35 mm/hr. Anne Zeller, CMA (AAMA)
Chapter Summary Providers rely on hematology tests for accurate diagnosis and treatment of patients. Along with urinalysis, these commonly ordered tests can be performed in-house utilizing automated analyzers, which are fast, accurate, and simple to use. While the medical assistant might not perform all hematology tests discussed, the medical assistant must be familiar with test methods and the rationale behind each. It is usually the duty of the medical assistant to receive and screen all lab reports and alert the provider of any abnormal results.
FIELD APPLICATION CHALLENGE You are asked to obtain blood samples for a CBC and a chemistry profile. The patient is a difficult draw. The clot tube fills to the appropriate level, but the EDTA tube stops filling at the halfway point. You complete the venipuncture and gently mix the EDTA tube. The patient is dismissed, and the samples are prepared for transport to the laboratory.
1. Will the EDTA tube produce accurate test results? Why or why not? 2. What should you have done to remedy the situation?
Chapter Assessment 1. Which hematology test would be increased with an inflammatory condition? a. Hemoglobin b. Hematocrit c. ESR d. Differential
4. By measuring hemoglobin, we are indirectly measuring the __________ of the red blood cells. a. color b. shape c. size d. oxygen-carrying capacity
2. The differential count categorizes which type of blood cell? a. Red b. White c. Platelet d. Thrombocyte
5. The cellular component responsible for aiding in blood clotting is: a. plasma. b. thrombocyte. c. leukocyte. d. erythrocyte.
3. The volume of packed red cells is known as the: a. hematocrit. b. hemoglobin. c. ESR. d. WBC.
6. Which white blood cell is elevated during an allergic reaction? a. Monocyte b. Lymphocyte c. Basophil d. Eosinophil
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Web Activities 1. Search the Web for information on different types of anemias and leukemias. 2. Visit http://www.cdc.gov to determine guidelines for handling stained blood smears.
THE DVD LINK On your StudyWARE CD-ROM, go to the DVD Challenge for this chapter. View the DVD clip and respond to the following questions: 1. What is the purpose of an ESR?
CONNECTION Using your StudyWARE CD-ROM: ❖ Complete the Hangman activity for this chapter. ❖ Complete the Quiz for this chapter in Test Mode.
2. Why is timing so crucial? 3. The medical assistant should measure where the red cells meet the ___________ in order to gain a proper measurement.
C H A P T E R
Microbiology
Essential Terms
Chapter Outline Classification of Microorganisms Divisions of Microbiology Binomial Nomenclature System for Bacteria Characteristics of Bacteria Basic Bacterial Cell Structure Morphology of Bacteria Classification by Staining Reaction Specimen Collection and Safe Handling Requirements General Specimen Collection Guidelines Specific Specimen Collection Requirements Identification of Bacteria The Culture
Growth Media Direct and Biochemical Tests Streptococcus Identification Rapid Strep Tests Sensitivity Testing Special Microscopic Techniques The Wet Mount Hanging Drop Method Virology Identification of Viruses Parasitology Identification of Parasites Mycology Identification of Fungi Quality Control
Developmental Objectives After completing this chapter, you should be able to: 1. Correctly spell and define the essential terms. 2. Explain taxonomy.
29 aerobic agar anaerobic bacilli bacteria cocci colony culture culture and sensitivity (C&S) test culture medium fastidious fungi Gram negative Gram positive Gram stain incubation inoculation microbiology normal flora opportunistic infection parasite pathogen continues
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KEY COMPETENCIES
CAAHEP
ABHES
Preparing a Urine Specimen for Culture and Sensitivity Using a Urine Transport System
III.C.3.b.1.d III.C.3.b.1.e III.C.3.b.2.c
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Collecting a Throat Specimen and Performing a Rapid Strep Test
III.C.3.b.1.d III.C.3.b.1.e III.C.3.b.2.c
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Collecting a Wound Specimen
III.C.3.b.1.d III.C.3.b.1.e III.C.3.b.2.c
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Preparing a Wet Mount or Hanging Drop Slide
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VI.A.1.a.4.j VI.A.1.a.4.q VI.A.1.a.4.r
Instructing a Patient on Fecal Specimen Collection for Ova and Parasite Testing
III.C.3.b.2.e
VI.A.1.a.4.x
pathogenic pure culture sensitivity testing taxonomy virus
3. Describe the difference between bacteriology, virology, parasitology, and mycology. 4. List and describe bacterial morphology. 5. Explain the significance of normal flora. 6. Describe the difference between bacteria that is Gram positive and bacteria that is Gram negative. 7. List common guidelines for specimen collection. 8. Explain the purpose of culture and sensitivity testing. 9. Explain the purpose of a wet mount. 10. Explain the three methods used to identify viruses. 11. Describe the purpose of using a safety hood when working with molds.
Introduction The field of medical microbiology includes the study of microscopic organisms such as bacteria, viruses, parasites, and fungi. While many microorganisms are present in nature, only a small percentage are pathogenic or disease producing. Some microbes, known as normal flora, are actually helpful and necessary to maintain a balance in certain areas of the body. This chapter will discuss the more common microorganisms and the diseases they cause, along with test methods used to isolate and identify them. Since new microbes are always being discovered, the medical assistant should strive to continuously update knowledge in this ever-expanding area.
CLASSIFICATION OF MICROORGANISMS Microorganisms are usually classified using a set of laws and principles known as taxonomy. Since no universal agreement exists on which system is best, several different methods are often used for classification.
MICROBIOLOGY
Originally, living organisms were divided into two kingdoms: plant and animal. After the invention of the microscope, a new kingdom of microscopic organisms known as Protista were discovered. Since most microorganisms are neither plant nor animal, these one-celled organisms were classified as protists. Two groups of protists are present in medicine: lower protists or prokaryotes, which include bacteria and bluegreen algae, and higher protists or eukaryotes including protozoa, algae, and fungi.
DIVISIONS OF MICROBIOLOGY Within the microbiology department of a laboratory, a multitude of specimens are processed and tested. Results obtained from these studies aid in the diagnosis, treatment, and prevention of diseases. In larger reference laboratories, the microbiology department is usually divided into the following subdepartments or specialized areas of study: ❖ Bacteriology: This area is usually the largest and is responsible for the growth, isolation, identification, and study of bacteria. ❖ Virology: This is the area responsible for the study of viral diseases. ❖ Parasitology: This is the area responsible for the identification and study of parasites ❖ Mycology: This subdivision studies fungi, including yeasts and molds. Along with isolating and identifying microorganisms, the microbiology department plays an important role in conjunction with the infection control department of the hospital in determining the causes of nosocomial (hospital acquired) infections. These infections must be quickly identified and closely monitored to prevent their spread. Patients with suppressed immune systems are quite susceptible to these opportunistic infections. The microbiology department also has a responsibility to notify the Public Health Department when certain types of organisms are grown and identified from patient samples. Each state and metropolitan area has its own guidelines for reporting these communicable diseases; health care workers must be aware of the regulations in their area. Common reportable organisms include: ❖ Salmonella: The normal causative agent of severe food poisoning ❖ Shigella: The normal causative agent of mild to severe dysentery
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❖ Sexually transmitted diseases (STDs): Organisms that cause gonorrhea, syphilis, chlamydia, and genital herpes
BINOMIAL NOMENCLATURE SYSTEM FOR BACTERIA Bacteria (single-celled microbes lacking a nucleus) are named using a binomial (two name) system. The first name is the genus and is capitalized; the second name is the species and is not capitalized (for example, in Escherichia coli, Escherichia is the genus and coli is the species). Bacteria that possess similar characteristics belong to the same genus, or family. For example, Staphylococcus aureus and Staphylococcus epidermidis are members of the genus Staphylococcus, but have different species names due to specific characteristics. Many bacteria are named for people or places related to their discovery; for example, Legionella pneumophilia, which causes Legionnaire’s disease, was first noted following an American Legionnaire’s convention in 1976, where 34 attendees died from the disease.
CHARACTERISTICS OF BACTERIA All bacteria possess individual characteristics that aid in their identification. The features used as criteria for recognition include structure, morphology, and staining characteristics.
Basic Bacterial Cell Structure Every cell of every living structure contains DNA (deoxyribonucleic acid), which carries the genetic information specific to that entity. A bacterial cell (Figure 29-1) is a single-celled organism that possesses a cell membrane, a cell wall, and a nucleus. This particular type of cell takes in nutrients from the environment for growth, function, and reproduction through cell division. Some bacteria are nonmotile; they do not possess a flagellum, which is necessary for movement. Other forms of bacteria produce a protective covering around the cell wall (known as a capsule) that can make them resistant to certain antibiotics and protect them from attack by white blood cells. Certain bacteria produce spores that can remain inactive for as long as 150,000 years. Spores are extremely hard to kill and are resistant to heat, freezing, radiation, and certain chemicals.
Morphology of Bacteria The microbes that most commonly cause diseases in humans are bacteria and viruses. Bacteria are
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Capsule
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FI E L D S M A R T S Cell wall Nucleoid material
Cytoplasmic membrane Ribosomes
Because of their tough capsule, spores are resistant to most chemical disinfectants and even boiling temperatures. The best means of destroying spores is by autoclaving. All critical devices that enter nonintact skin must be sterilized in an autoclave to ensure that all microbes—including those that produce spores—have been destroyed. Some chemical sterilants also claim to kill spores.
Flagellum
Cocci
FIGURE 29-1 Bacterial cell structure
categorized according to their morphology, or shape, and their reactions to Gram staining. Bacterial morphology is divided into three basic shapes: ❖ Cocci: Round shaped ❖ Bacilli: Rod shaped ❖ Spirilla: Spiral shaped The shapes of bacteria may be further identified according to the way they are grouped: ❖ The prefix mono- is used when describing single fragments. ❖ The prefix diplo- is used for bateria occurring in pairs. ❖ The prefix strepto- is used for bacteria occurring in chains. ❖ The prefix staphylo- is used for bacteria occurring in clusters.
Round-shaped bacteria, or cocci, can occur in pairs (diplococci), chains (streptococci), or clusters (staphylococci). Figure 29-2 illustrates the three different configurations. Diplococci (Figure 29-2a) are responsible for diseases such as meningitis, gonorrhea, and pneumonia. Streptococci (Figure 29-2b) are the cause of strep throat, certain types of pneumonia, rheumatic fever, scarlet fever, and some skin conditions like impetigo. A species of staphylococci (Figure 29-2c) known as Staphylococcus epidermidis is present as normal flora on the skin, in the mucous membranes of the nose, throat, mouth, and intestines, and normally does not pose a problem. However, a small abrasion or break in the skin can allow the normal flora to enter the tissues and cause an infection. Another species known as Staphylococcus aureus is responsible for infections that produce large amounts of pus, such as abscesses, boils, impetigo, and carbuncles. Staphylococcus bacteria can also cause certain forms of food poisoning.
Bacilli Rod-shaped bacteria, or bacilli, can possess a rounded, straight, or pointed end. They may also possess flagella
FIGURE 29-2 Bacteria classified as cocci: (a) occurring in pairs, (b) occurring in chains, (c) occurring in bunches
Diplococcus
Streptococcus
Staphylococcus
(a)
(b)
(c)
MICROBIOLOGY
that make them motile (able to move from one place to another). One species of bacilli, Escherichia coli, is present in the intestinal tract as normal flora; however, it can be the cause of a UTI if it enters the urinary tract due to poor hygiene. Different species of bacilli are also found in the soil and air and are often responsible for serious diseases, such as typhoid fever, pertussis (whooping cough), diphtheria, tuberculosis, botulism, and tetanus. Bacilli may also be spore forming, allowing them to withstand extreme temperatures and particular chemicals in disinfectants, making them viable for decades. Figure 29-3 illustrates the different types of bacilli.
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C R I T I C A L T H I N K I NG CHALLENGE How would you classify bacteria that are round in shape, purple in color, and appear in chains? How would you classify single rod-shaped bacteria that appear pink in color? If the rod-shaped bacteria also contained a flagellum, it would be further classified as _______, meaning that it has the ability to move from one area to another.
Spirilla Most spiral-shaped bacteria are motile. They are responsible for a number of diseases, such as syphilis and cholera. The spirochete, Treponema pallidum, the causative agent of syphilis, cannot be grown on common culture medium; therefore, syphilis must be diagnosed by testing blood serum for the presence of the spirochete. Cholera, caused by another spirillum (Vibrio cholerae), has virtually been eliminated in the United States due to proper sanitation practices, water purification, and the development of the cholera vaccine. Figure 29-4 illustrates the morphology of spirilla.
Classification by Staining Reaction Bacteria are often classified by their reaction to different dyes or stains. These stains are used to give color
to the bacteria, making them more visible under the microscope. Stains are either basic or acidic and are classified as a simple or differential stain. A simple stain illustrates the structure and arrangement of the bacterial cells, but does not provide much other information. A differential stain is one that produces variable results based on the composition of the bacterial cell wall. A common differential staining method, the Gram stain, was developed over 100 years ago by Dr. Hans Christian Gram and is still used today. This method differentiates bacteria based on their color reactions to various stains. During the Gram stain process, bacteria are placed on a slide and stained with a primary purple stain (crystal
FIGURE 29-3 Bacteria classified as bacilli: (a) with flagella for motility, (b) occurring in pairs, (c) occurring in chains
Flagella
Bacillus (flagellated)
Diplobacillus
Streptobacillus
(a)
(b)
(c)
FIGURE 29-4 Spiral-shaped bacteria: (a) spirilla, (b) spirochete
Spirilla
(a)
Spirochete
(b)
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violet), flushed with a mordant or fixative (iodine), and then treated with a decolorizer (acetone/alcohol). Some bacteria retain the purple color after decolorization and are classed as Gram positive (Figure 29-5). Others cannot retain the dye after being decolorized and must be counterstained with a red dye (safranin) to make them visible under the microscope. These bacteria are classed as Gram negative and appear pink in color (Figure 29-6). The Gram staining characteristics along with the morphological arrangement of the bacteria are often the only information the physician requires to begin treatment.
FIGURE 29-5 Gram positive Streptococci exhibiting the characteristic purple color
Another type of differential stain used to identify organisms that do not react well to Gram stain is the acid-fast stain. Acid-fast organisms resist staining due to a waxy capsule that surrounds the cell wall. Heat or a powerful dye is needed to stain such organisms. Several species of Mycobacterium, such as those that cause diseases such as tuberculosis, leprosy, and pulmonary disease, are examples of acid-fast organisms. Two common methods used to stain acid-fast organisms are the Ziehl-Neelsen and Kinyoun stains.
SPECIMEN COLLECTION AND SAFE HANDLING REQUIREMENTS The physician must identify the pathogen causing a specific condition before implementing proper treatment. For example, a sore throat such as one caused by the bacteria Streptococcus would be treated with an appropriate antibiotic. If a virus is causing the sore throat, an antibiotic would be ineffective. Proper specimen collection and handling is essential to ensure accurate identification of the pathogen. When collecting microbiological specimens, growth requirements such as moisture, temperature, oxygen, carbon dioxide, and special nutrients must be considered. Some bacteria require oxygen for growth and are referred to as aerobic; others grow only in the absence of oxygen and are referred to as anaerobic.
General Specimen Collection Guidelines
FIGURE 29-6 Gram negative rods exhibiting the characteristic pink color
The medical assistant is often the person responsible for obtaining specimens for microbiological studies and must follow certain guidelines to ensure accurate results. The following general guidelines will help to ensure proper specimen collection and preservation: ❖ The specimen should be collected before antibiotics are administered. ❖ Sterile supplies should be used to collect and preserve the specimen. ❖ The specimen should be collected from the site of infection, not the surrounding areas. Contamination of the specimen with unrelated bacteria, such as normal flora, may make it difficult to identify. ❖ Be sure to collect a sufficient amount of the specimen. ❖ Immediately place the specimen in the appropriate container and transport media, following the directions packaged with the media. Transport media keeps the specimen moist and viable until testing can be performed. Figure 29-7 illustrates a variety of collection and transport systems.
MICROBIOLOGY
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SITE CHECK
FIGURE 29-7 Examples of different transport media and specimen collection containers
❖ Appropriately label the specimen with the patient’s name, date of collection, source of the specimen, and your initials. ❖ Send the specimen to the laboratory within the appropriate time limit. Safe handling of microbiology specimens is crucial to prevent the spread of disease. The following precautions should be observed: ❖ Handle all specimens as if they contain pathogens. ❖ Wear appropriate PPE when collecting and handling specimens. PPE should consist of gloves, lab coat or apron, and safety goggles or a face shield. ❖ PPE should be removed before leaving the work area.
As an insurance site inspector, I will check that proper safety precautions are being instituted when employees perform microbiology procedures, such as collecting and handling specimens and performing tests from rapid test kits. I will also check quality control logs, and temperature logs for refrigerator, freezer, and incubator readings. Following OSHA guidelines when performing microbiology procedures can help to prevent the unnecessary spread of infectious disease.
❖ Check specimen containers for leaks before placing into protective bags. ❖ Place specimen containers in an outside protective bag to protect those handling the specimen. ❖ Clean spills and work surfaces with 5% phenol or a 10% bleach solution.
Specific Specimen Collection Requirements When obtaining specimens for microbiology testing, it is necessary to strictly adhere to collection protocol. The majority of specimens must be placed in a sterile container and properly preserved until testing can be conducted. Table 29-1 lists information on the most common types of specimens collected in the physician’s office.
TABLE 29-1 Specimen Collection Requirements SPECIMEN TYPE COLLECTION REQUIREMENTS
PRESENCE OF NORMAL FLORA
POSSIBLE PATHOGENS
Urine
A clean-catch midstream specimen is preferred. Yes A sterile specimen container should be used to collect the specimen. Catheterization is performed when a sterile specimen is absolutely necessary. The specimen is placed in a sterile container.
Pseudomonas species Klebsiella-Enterobacter species Proteus species E. coli
Blood
Collected by venipuncture with a variety of collection devices using strict sterile technique
Staphylococcus aureus E. coli Staphylococcus epidermidis Enterococcus Pseudomonas species Streptococcus pneumoniae Bacteroides Clostridium Mycobacterium species Candida species Cryptococcus neoformans
No
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TABLE 29-1 Specimen Collection Requirements (continued) SPECIMEN TYPE
COLLECTION REQUIREMENTS
PRESENCE OF NORMAL FLORA
POSSIBLE PATHOGENS
Cerebrospinal fluid (CSF)
Fluid is obtained by lumbar puncture using strict sterile procedure. Usually performed by a physician and placed in a sterile vial.
No
Haemophilus influenzae Neisseria meningitidis
Sputum
A morning specimen is required, collected from deep cough. Expectorated material is placed in a special container.
Yes
Streptococcus pneumoniae Staphylococcus aureus Klebsiella pneumoniae Streptococcus pyogenes (group A strep) Haemophilus influenzae Neisseria species Legionella species
Stool
A sterile container is not required. Several specimens may be required. The specimen must not be contaminated with urine.
Yes
Salmonella species Shigella species Giardia lamblia Entameoba species
Wound
A specimen may be aspirated from a pusfilled wound with a sterile needle. The specimen may be obtained by placing a sterile swab deep within the wound. Avoid touching the surrounding skin. The specimen should be placed in anaerobic transport media.
No
Staphylococcus aureus Streptococcus pyogenes Pseudomonas aeruginosa Proteus species Clostridium species E. coli
Genital
A specimen is collected by a sterile swab or thin wire.
Yes
Trichomonas vaginalis Neisseria gonorrhea Chlamydia trachomatis Candida albicans Streptococcus agalactica (group B strep)
Nasal
A sterile swab or thin wire is gently inserted into each nostril and then placed into a sterile tube for transport. Use a separate swab for each nostril.
Yes
Bordetella pertussis Staphylococcus aureus
Throat
Use a sterile tongue depressor to hold down the tongue and swab the back portion of the throat and tonsils, if present. Do not swab the sides of the mouth or the tongue. Place the specimen in a sterile tube for transport.
Yes
Streptococcus pyogenes or group A strep
Eye
Most specimens are collected by an ophthalmologist. Moistened sterile swabs are touched to the affected area of the eye.
Yes
Staphylococcus aureus Streptococcus pyogenes Pseudomonas aeruginosa Haemophilus influenzae
Ear
Gently cleanse the ear canal and use a sterile swab. The provider may collect fluid from the inner ear with a needle and syringe.
Yes
Staphylococcus aureus Streptococcus pyogenes Pseudomonas aeruginosa Haemophilus influenzae
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CR ITI C A L TH I N K I N G C H AL LEN G E When collecting a wound specimen, you accidentally touch the edge of the skin when withdrawing the swab. 1. What should you do?
IDENTIFICATION OF BACTERIA Many microorganisms dwell in nature within soil and water. Some reside in areas of the human body as normal flora. These micoorganisms do not pose any threat to the host and, in fact, provide protection by competing for nutrients that might otherwise be used by pathogenic organisms. They are therefore helpful to the body. Normal flora is found on the skin, in the mouth, in the respiratory tract, and in the intestines. Only a small quantity of the bacteria in existence are actually pathogenic. Proper identification and isolation of a pathogen is essential in determining the diagnosis of a condition and the desired treatment method. In order to identify which pathogen is causing the patient’s condition and which antibiotic will most likely destroy the organism, the provider will order a culture and sensitivity (C&S) test. The culture grows and identifies the organism and the sensitivity portion of the test determines which antibiotic is most effective against the organsism. Most specimens such as wound, blood, and sputum may be collected in the medical office, but are generally sent to an outside reference laboratory for identification. Throat and urine cultures are also usually sent out for testing; however, some physician’s office labs (POLs) that are moderately complex may still perform them in-house. Identification of some common bacteria can often be made from a simple smear and Gram stain, while other species may be more difficult to identify. Some organisms require special growth media, stains, and biochemical tests.
The Culture The culture is defined as a group of microbes growing on nutrient-rich media. Following specimen collection, microorganisms must be placed on an appropriate culture medium to facilitate proper growth and isola-
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tion for identification purposes. Cultures are usually grown in a Petri dish, which is a small, shallow circular plate made of clear plastic (Figure 29-8). The Petri dish is covered with a lid to help protect its contents. The Petri dish or culture plate holds a growth medium that contains special nutrients to support and encourage microbial growth. Because the plate is clear, a culture can be observed without removing the lid. This prevents possible contamination of the culture and helps to prevent any pathogens from being released into the air as an aerosol. Figure 29-9 illustrates a bacterial culture after growth has been established. The visible areas of growth are known as colonies. Colonies of different
FIGURE 29-8 A Petri dish containing blood agar
FIGURE 29-9 Bacterial growth on sheep’s blood agar (note the individual colonies)
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microorganisms often have a characteristic appearance, which can be observed on the culture. This can be the first or preliminary step in identifying the microbe. The first or original culture is known as the primary culture. After 24 to 48 hours of incubation and growth, the colonies are observed for differing characteristics. If the culture contains more than one organism, known as a “mixed culture,” each organism is separated and plated on the appropriate media. This new culture is known as a subculture. The object of subculturing is to yield a pure culture that contains only one organism.
Growth Media The media used to grow microorganisms can be a liquid broth, a semisolid, or a solid known as agar (Figure 29-10). Agar is a gelatin-like substance containing additives and nutrients that will support the growth and multiplication of microorganisms. Some organisms require additives such as vitamins, minerals, sugars, salts, amino acids, and even eggs, potatoes, meat, blood, and certain dyes to grow well in a laboratory environment. Commercially prepared culture plates usually come in protective plastic sleeves to prevent the media from drying out and should always be stored in a refrigerator. Condensation tends to form on the lid of the Petri dishes, so the plates should be placed in the refrigerator with the lids facing down to prevent moisture from dripping onto the agar. Growth media contained in culture plates is classified into the following general categories: ❖ Enriched: Enriched media contains additives that encourage the growth of some bacteria, while
FIGURE 29-10 Different types of growth media including broth, semisolid tube media, and agar plates
inhibiting the growth of others. It is used for cultures from sites that contain normal flora, like the throat or mouth. Enriched media will inhibit the growth of the normal flora, while promoting the growth of the pathogenic organism. ❖ Selective: Selective media promotes the growth of one type of bacteria while inhibiting the growth of others. Chemicals, dyes, salts, and even antibiotics are added to selective media. ❖ Differential: Differential media is also known as indicator media. It contains certain substances that will alter the appearance of the colonies, usually in the form of a color change. For example, MacConkey agar contains the sugar lactose, and will distinguish between lactose-fermenting organisms, which appear pink, and non-lactosefermenting organisms, which will appear clear. Table 29-2 lists some common types of growth media and their uses.
Inoculating the Media Microbiology specimens must be placed on culture media through a process known as inoculation. Quite simply, inoculation is transferring some of the microorganism onto growth media from the original collection swab. Once the specimen has been inoculated onto the media, it must be spread out, or streaked, on the plate. A common streaking method involves dividing the plate into four quadrants. The specimen is inoculated onto the plate by pulling the original swab over the center of the first quadrant. A sterile loop is then used to spread the specimen over the media to the remaining three quadrants (greatly thinning out the cells from one quadrant to the next). The four-quadrant method of streaking the culture plate, illustrated in Figures 29-11 and 29-12, is utilized to thin or dilute the specimen for easier isolation of the colonies. The following guidelines should be followed when performing the four-quadrant streaking method: ❖ Remove the culture plate from the refrigerator and allow it to warm to room temperature. Plating a specimen on a cold plate will kill microorganisms that may be present on the specimen swab. ❖ Culture plates have an expiration date. Always check the expiration date before plating a specimen and do not use expired plates. ❖ When streaking the plate using the four-quadrant method, hold the plate in the nondominant hand and perform the streaking with the dominant hand. (Remember that the initial inoculation
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TABLE 29-2 Common Types of Culture Media MEDIA
CLASSIFICATION
ADDITIVES
USES
Blood agar (BA) or sheep’s blood agar (SBA)
Enriched and differential
Sheep’s blood
General all-purpose use; promotes the growth of most Gram positive and Gram negative organisms; exhibits hemolysis, or destruction, of the red cells in the agar
Chocolate agar
Enriched
Hemoglobin
Provides heme (an iron-containing protein) for fastidious or difficult to grow organisms like Neisseria and Haemophilus
Thayer-Martin (TM)
Selective
Contains antibiotics
Suppresses the growth of normal flora; selective for Neisseria species
MacConkey
Selective
Contains lactose and indicators
Used to isolate and differentiate lactose-fermenting organisms
Eosin-Methylene Blue (EMB)
Selective and differential
Contains lactose, sucrose, eosin, and methylene blue dyes
Differentiates lactose-fermenting organisms; promotes growth of Gram negative organisms
Hektoen-Enteric agar (HE)
Selective
Bile salts and dyes
Promotes the growth of Salmonella and Shigella
FIGURE 29-11 Blood agar plates showing examples of the fourquadrant streaking method
FIGURE 29-12 Bacterial growth in each quadrant when streaked as shown in Figure 29-11
will be with the original swab, while the remainder of inoculating will be performed with a sterile loop.) ❖ Replace the lid immediately after streaking. Agar should not be unnecessarily exposed to the air. Drying and contamination may result.
❖ Label the bottom of the plate and place in the incubator bottom- or agar side–up for the prescribed amount of time (24 to 48 hours). Placing the plate agar side–up prevents the condensation that forms on the lid from dripping onto the culture (Figure 29-13).
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FIGURE 29-13 Placing a culture plate in the incubator bottomup to prevent condensation from dripping onto the colonies
Special streaking techniques are used for antibiotic sensitivity testing and urine colony counts. These techniques involve spreading the specimen across the entire plate. Antibiotic sensitivity testing will be discussed later in the chapter.
Direct and Biochemical Tests Initial examination of the culture and a Gram stain is sometimes all that is necessary to identify a pathogen; however, many bacteria have such similar characteristics that further testing is required. TABLE 29-3 Common Direct Tests for Bacterial Identification DIRECT TEST
FUNCTION
Catalase
Differentiates Staphylococcus from Streptococcus
Coagulase
Differentiates species of Staphylococcus to determine the proper antibiotic for treatment
In some cases, a direct test, which is easily performed, will yield a final identification of a microorganism. But in other cases, a direct test will indicate the need for additional testing. Biochemical tests can be performed by placing isolated colonies of microorganisms in different tube media and observing the reaction. Table 29-3 lists common direct tests used to identify microorganisms and Table 29-4 lists some of the common biochemical tests used for identification. While the medical assistant will not be performing these tests, a basic knowledge of which bacteria each test can identify will help when reviewing lab results. Biochemical tests are also available in packaged systems for identifying certain types of bacteria. Automated instruments that test samples are also available. The identification systems and automated instruments are used in large hospitals and reference laboratories. Microbiologists can now set up a machine and walk away; all the work and identification will be performed automatically.
Streptococcus Identification Because several species of Streptococcus exist, it is necessary to identify which of the species is causing a particular condition. The most common condition caused by a Streptococcus species is strep throat, which is caused by Streptococcus pyogenes, a group A beta-hemolytic Streptococcus. Positive identification of this species will ensure that the proper treatment is implemented quickly. Some patients can develop serious secondary post-strep infections (such as rheumatic fever), making rapid identification paramont.
TABLE 29-4 Common Biochemical Tests for Bacterial Identification BIOCHEMICAL TEST
FUNCTION
Citrate utilization
Presumptive identification of Neisseria species
Indicates species of Enterobacter, Citrobacter, Klebsiella, and Yersinia
Urease utilization
Indicates Proteus species
Indole
Positive result indicates E. coli and Proteus species
Substrate fermentation tests
Indicates Enterobacteriacae
Bile solubility
Detects Streptococcus pneumoniae
Bile esculin
Indicates Streptococcus species
Oxidase
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Streptococcus species are categorized into 15 groups, indicated A through O, and are further classified by their ability to hemolyze the red blood cells in blood agar. The different species of Streptococcus can produce three types of hemolysis: ❖ Alpha hemolysis: Indicated by a greenish halo around the bacterial colonies on blood agar ❖ Beta hemolysis: Indicated by a wide clear zone around the colonies ❖ Gamma hemolysis: Indicated by no reaction on the blood agar
Bacitracin Testing One method of identifying group A beta strep is by performing a bacitracin test. A throat swab is obtained and the specimen is inoculated onto a blood agar plate. A paper disc impregnated with bacitracin and designated with “A” or “BAC” is then placed on top of the agar and the plate is incubated for the prescribed amount of time. Following incubation, the plate is observed for hemolysis and a clear zone of inhibition around the disc. Figure 29-14 shows a zone of inhibition around the bacitracin disk, indicating susceptibility and the presence of group A strep. Bacterial growth up to the disk would indicate resistance to bacitracin and the presence of a different species of strep. Bacitracin testing can easily be performed in the POL; however, with the development of rapid strep testing, it is used less frequently in the POL due to the time required to obtain results. The provider may request a culture to be sent out to confirm the results of a rapid strep test, particularly if the rapid strep test was negative. Another type of test that can be performed utilizes a “P” disc impregnated with optichin. This test will detect the presence of Streptococcus pneumoniae in patients with pneumonia.
Rapid Strep Tests As mentioned, strep throat can now be diagnosed quickly while the patient is still in the office by performing a rapid strep test. The rapid test can produce results in five minutes or less, may be CLIA waived, and can easily be performed by the medical assistant. Several companies manufacture rapid strep tests, but this text features the QuickVue® test method by Quidel. Figure 29-15 illustrates the three QuickVue methods for the detection of group A strep. Refer to Procedure 29-2 for instructions on how to properly perform the tests. A throat swab is collected (see Procedure 29-2) and tested by one of the methods shown. Each kit includes
FIGURE 29-14 A clear zone of inhibition around the bacitracin disk indicates a positive for strep. If the bacteria grows up to the disk, it is negative for strep.
controls to ensure test accuracy. Interpretation is quick and easy, and treatment can begin immediately.
SENSITIVITY TESTING Once the pathogen has been identified, the provider must determine which antibiotic will work best to destroy the pathogen. The answer often comes from the results of susceptibility or sensitivity testing. Several test methods are used to determine the sensitivity of a microorganism to an antimicrobial agent or antibiotic, the most common of which is a discdiffusion method known as the Kirby-Bauer method. This test is performed by placing paper discs containing a known concentration of an antibiotic on top of a plate that has been inoculated with the pathogen. The plate is then incubated for 24 hours while the antibiotics diffuse into the agar. If an antibiotic inhibits the growth of the organism, a clear zone of no growth will appear around the disk (Figure 29-16a) and it is said that the organism is susceptible or sensitive to that particular antibiotic. If the organism is resistant to or unaffected by the antibiotic, it will grow up against the disc with no clear zone present (Figure 29-16b). The zones of inhibition are measured and the organisms are classified as follows: ❖ (R) resistant: The antibiotic will not have any affect on the organism. ❖ (I) intermediate: The organism will be partially destroyed by the antibiotic.
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Strap A Strap A Strap A Strap A Strap A Strap
QUICKVUE DIPSTICK STREP A PROCEDURE
5 Min.
B
A
x5
1 Min.
3 drops
Wait 1 minute
Express all liquid
Read results at
from swab
5 minutes
QUICKVUE+ STREP A PROCEDURE x5
B
A
1
2
QUI
CK VUE +
QUICK VUE+
QUICKVUE IN-LINE STREP A PROCEDURE Wait 5 minutes
5
Sterile Swab
QuickVue
QuickVue
Sterile Swab
Break
Shake
Insert completely
FIGURE 29-15 Three meth-
Quickly fill to rim
ods of the QuickVue rapid strep test by Quidel (Courtesy of Quidel Corporation.)
FIGURE 29-16 Sensitivity testing indicating varying sizes of zones of inhibition for different antibiotics: (a) sensitive and (b) resistant
(a) (b)
❖ (S) sensitive/susceptible: The antibiotic will destroy the organism. Manufacturers’ guidelines should be followed for determining the zone sizes for resistant, intermediate, and sensitive/susceptible.
SPECIAL MICROSCOPIC TECHNIQUES Microorganisms are usually examined microscopically in either a living state or a fixed state. A fixed state exam involves the preparation of a smear made directly from the specimen or from the culture itself. The smear is then heat-fixed so the cells will adhere to the slide. Then the smear is stained with special dyes to make the organism more visible. A living state exam requires the organism to first be suspended in a liquid, such
MICROBIOLOGY
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In recent years, several strains of antibioticresistant bacteria have emerged. Scientists believe that microbes learn to adapt to their environment, making changes over time to their genetic structure so that drugs that were once effective are no longer effective. As more and more people take antibiotics for specific organisms, those organisms continue to make changes in their DNA and eventually become known as super microbes (microbes resistant to antibiotics). The CDC and other world health organizations now caution physicians not to treat patients with antibiotics unless it is absolutely necessary.
as normal saline. The suspension itself is then examined microscopically by using preparation methods known as the wet mount procedure or the hanging drop procedure.
The Wet Mount The wet mount procedure involves placing a drop of bacterial suspension on a slide and gently covering the drop with a cover slip coated around the edges with petroleum jelly. This forms a seal to prevent drying of the specimen (Figure 29-17). The wet mount procedure is commonly used to diagnose the cause of vaginosis. The specimen is examined for the presence of “clue cells,” or epithelial cells covered with coccobacilli. The motility (movement) of Trichomonas vaginalis may also be observed by this method. Examination is performed under high-power, low-intensity light. Procedure 29-4 lists the steps necessary to prepare a wet mount.
Hanging Drop Method The hanging drop is a special type of wet mount that is also used to ascertain motility. To prepare a hanging
Patients should avoid taking leftover medication from a previous illness, or accepting medication from a friend or family member. Patients should also be instructed to take all of their medication, even if they start to feel better after only a few days. The antibiotic may have wiped out enough organisms to relieve symptoms, but the bacteria may not be fully destroyed. They still live in the body, changing their chemical structures so that eventually the patient becomes ill again—but may not respond to the same medication during the next bout.
TOOL BOX
PAT I E N T T U T O R
drop, a drop of bacterial suspension is placed in the center of a cover slip with petroleum jelly around the edges. A slide with a concave well is placed over the drop on the cover slip, and gentle pressure is applied to form a seal. The slide is then inverted and placed on the microscope so the drop is examined as it hangs from the cover slip (Figure 29-18). Procedure 29-4 lists the steps required to prepare a hanging drop slide. Since a multitude of bacteria exist in nature and are capable of causing many different conditions, Table 29-5 was developed as a quick reference for some of the most common bacteria encountered in the medical office and the diseases they cause.
FIGURE 29-18 Example of a hanging drop slide: (a) the specimen is placed on a cover slip rimmed with petroleum jelly, not on the slide itself; (b) a clean glass slide with a well is placed over the cover slip; (c) the slide is inverted, so the drop hangs from the cover slip for examination.
FIGURE 29-17 An example of a wet mount slide—a cover slip rimmed with petroleum jelly is placed over the drop of the specimen.
(a)
(b) (c)
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TABLE 29-5 Common Bacteria and Related Diseases MICROORGANISM
DISEASE
Staphylococcus aureus
Skin and wound infections UTI Pneumonia Food poisoning Toxic shock syndrome
Staphylococcus epidermidis
Wound infections Nosocomial infections
Streptococcus pyogenes (group A strep)
Acute pharyngitis Sequelae: scarlet fever, rheumatic heart disease, glomerulonephritis Necrotizing fasciitis
Streptococcus pneumoniae
Pneumonia
Streptococcus agalactiae (group B strep)
Bacterial sepsis Meningitis in newborns
Enterococci
Nosocomial infections
Escherichia coli
UTI Diarrhea Sepsis Neonatal meningitis
Neisseria species
Meningitis Gonorrhea Urethritis Pelvic inflammatory disease (PID)
Proteus species
UTI
Haemophilus influenzae
Sinusitis Pneumonia Meningitis Otitis media
Klebsiella pneumoniae
Lobar pneumonia
Salmonella species
Typhoid fever Bacteremia Food poisoning Diarrhea
Shigella species
Dysentery
Bordetella pertussis
Whooping cough
Citrobacter
Opportunistic infections UTI Neonatal meningitis
Gardnerella vaginalis
Bacterial vaginosis
Yersinia
Plague
Legionella
Pneumonia or Legionnaire’s disease
MICROBIOLOGY
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TABLE 29-5 Common Bacteria and Related Diseases (continued) MICROORGANISM
DISEASE
Bacillus species
Anthrax Endocarditis Food poisoning Septicemia Meningitis
Pseudomonas species
Opportunistic infections Drug-resistant nosocomial infections Wound and burn infections
Listeria species
Listeriosis food poisoning Encephalitis Meningitis
Helicobacter pylori
Gastritis Peptic ulcer
Corynebacterium species
Diphtheria
Vibrio species
Cholera
VIROLOGY A virus is the most common cause of infectious diseases in humans. They are responsible for such maladies as influenza (flu), measles, mumps, and the common cold. Viruses are known as obligate intracellular parasites because they can only duplicate or multiply after entering another living cell. Viruses are also the smallest of all microorganisms and therefore must be viewed with an electron microscope. Diagnostic virology is performed in larger clinical laboratories. Lab tests have been developed to facilitate prompt diagnosis of human immunodeficiency virus (HIV), human papilloma virus (HPV), hepatitis B (HBV), and hepatitis C (HCV) viruses.
While most small laboratories do not perform viral testing, specimens are often collected in the medical office. Most viruses will generally survive for 24 to 48 hours after collection if refrigerated, but some may require freezing for preservation. Instructions for specimen collection and transport are provided by the reference laboratory and should be strictly followed to ensure accurate identification. Table 29-6 lists some of the common specimens collected and tested for viral conditions. Refer to Table 29-7 for a listing of some common viruses, the pathogenic conditions they cause, and whether or not there is currently a vaccine available to prevent those diseases.
Identification of Viruses
PARASITOLOGY
Several methods are employed to isolate and identify viruses. The following are utilized for identification:
The clinical aspect of parasitology focuses on the study and identification of pathogenic parasites, the diseases they cause, and appropriate treatment methods. A parasite is an organism that lives in, on, or at the expense of another organism or host without assisting in its survival. A pathogenic parasite can cause illnesses spanning from infections that produce no symptoms, to gastrointestinal disorders with mild symptoms, to systemic infections that are life-threatening. Parasites can be unicellular or multicellular and may exist in any organ or system such as the blood, bone marrow, liver, spleen, skin, hair, or intestinal tract. The most common parasites found in the United States inhabit the blood, urogenital system, intestinal tract, skin, and hair.
❖ Cell culture: The cell culture is the standard identification method. Viruses are grown in a layer or suspension of living tissue cells. ❖ Direct detection: The viral antigen is detected in a patient specimen. ❖ Serodiagnosis: Virus antibodies are detected in the patient’s serum by ELISA (enzyme-linked immunosorbent assay) or EIA (enzymeimmunoassay) techniques. Diagnostic kits are available that detect common viruses such as influenza, rubella, and herpes simplex.
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TABLE 29-6 Common Viral Specimen Types SPECIMEN TYPE
DISEASE OR COMPLAINT
Stool sample Rectal swab
Gastrointestinal complaints
Serum
Cytomegalovirus (CMV) infection Epstein-Barr virus (EBV) infection
Hepatitis HIV infection
Swabs Scrapings
Vaginitis Cervicitis
Genital lesions
Cerebrospinal fluid (CSF)
Central nervous system conditions: Meningitis
Nasal/throat swab Urine Stool or rectal swab
Congenital/neonatal conditions: CMV Rubella
Nasal/throat swab Sputum Nasal/throat wash
Respiratory tract conditions: Pneumonia Croup
Pharyngitis Bronchitis
Vesicle fluid Lesion swab
Skin conditions: Maculopapules
Vesicular lesions
Encephalitis
TABLE 29-7 Viral Diseases VIRUS
DISEASE
IMMUNIZATIONS
Rhinovirus and coronavirus
Common cold
None
Influenza A, B, C
Influenza
Yes
Epstein-Barr virus (EBV)
Infectious mononucleosis
None
Human immunodeficiency virus (HIV)
AIDS
None
Human papilloma virus (HPV)
Genital warts and tumors
Yes
Respiratory syncytial virus (RSV)
Croup Bronchitis
None
Calicivirus
Adult gastroenteritis
None
Rotavirus
Gastroenteritis in infants and children
Yes
Herpes simplex type 1
Fever blisters
None
Herpes simplex type 2
Genital herpes
In progress
Varicella-zoster virus
Chicken pox Shingles
Yes Yes
Hepatitis B virus (HBV)
Hepatitis B
Yes
Hepatitis C virus (HCV)
Hepatitis C
No
PAT I E N T P E R S P E C T I V E As a patient, I certainly don’t always understand what is being said to me when I visit the physician, especially if I am not feeling well or am worried about what the physician may find. Remember to fully explain things like specimen collection clearly and in terms that I can understand. Keep in mind that some specimens, like
Parasites are identified by name first and further identified by stage of development. Stages include:
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Name
Identification of Parasites
a fecal specimen, are quite embarrassing to discuss. Please give me printed instructions to take home with me, so there is no question left unanswered when the office is closed. Be kind and patient. I’m not trying to be difficult—I’m only trying to make sure I understand all instructions given to me.
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TOOL BOX
MICROBIOLOGY
1. Slide with tape and label
❖ Trophozoite: Motile, multiplying form of protozoan (feeding and growing stage) ❖ Cyst: Dormant, non-motile protozoan ❖ Ova: Eggs of the parasite ❖ Larvae: Immature form ❖ Adult: Mature worm 2. Loop tape over end of tongue depressor to expose sticky surface
Visit the CDC’s Web site at http://www.cdc.gov or search for “cdc pdp” for a great collection of parasite images. Click on “professional” pages and PDx lab assistance. Proper specimen collection and preservation is essential for accurate identification of a parasite. The medical assistant must explain proper collection procedures to the patient for those specimens collected at home. The following are some common specimen requirements for parasite testing.
3. Press sticky surfaces against perianal areas Name
❖ Stool specimen (ova and parasites): Stool is usually collected in wide-mouth container, then a small aliquot, or portion, is placed in a vial with a preservative. One specimen is collected each day for three days. See Procedure 29-5, which lists the steps for proper collection of a fecal specimen for ova and parasite studies. ❖ Urine: A clean-catch midstream specimen is required. ❖ Vaginal/urethral discharge: A swab from the affected area is obtained. The specimen is set up for a wet mount. ❖ Blood: Draw a lavender top tube. The test is performed on stained smears. ❖ Pinworm: Cellophane tape test (Figure 29-19)
4. Replace tape
FIGURE 29-19 The steps required to prepare a cellophane tape slide for detection of pinworms
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small group are capable of causing disease. Most fungi are characterized as opportunistic and only cause disease in the following compromised patients and those taking certain medications:
TOOL BOX
CR ITI C A L TH I N K I N G C H AL LEN G E
❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖
A patient brings in a stool sample in a plastic bowl. Upon examination, you see that there is also a small amount of yellow fluid resembling urine in the container. 1. Is the specimen appropriate for testing?
Refer to Table 29-8 for a listing of some common parasites, specimen requirements, how they are transmitted, and the diseases or conditions they cause.
MYCOLOGY Mycology is the study of fungi, which includes yeasts and molds. Most fungi are nonpathogenic. Only a
Patients on antibiotic therapy Patients on corticosteroids Trauma patients Patients with diabetes mellitus Patients with lymphoid malignancies Patients with immune deficiencies like HIV Patients taking immunosuppressive drugs Patients who have had organ transplants
Identification of Fungi Fungal infections caused by yeasts often develop in patients on antibiotic therapy. Some yeasts are normal flora and are kept at a low level by the bacteria in that area of the body, which are also considered to be normal flora. As an antibiotic decreases the level of the pathogenic organisms, the level of normal flora is
TABLE 29-8 Common Parasites PARASITE
SPECIMEN REQUIRED
MEANS OF TRANSMISSION
DISEASE/CONDITION
Trichomonas vaginalis
Urine Vaginal/prostatic Secretions Urethral discharge
Sexually transmitted Common during pregnancy and following vaginal surgery
Vaginitis and discharge Prostatitis
Entamoeba histolytica
Feces
Ingested in contaminated food or water
Amoebic dysentary
Giardia lamblia
Feces
Ingestion of water or food contaminated with feces Most common parasite in the United States
Severe diarrhea
Necator americanus Feces or hookworm
Larvae in soil can penetrate the bare skin of the foot
Iron deficiency anemia–impaired growth in children
Cryptosporidium parvum
Feces
Ingestion of food or water contaminated with feces Oral-anal sexual contact Direct contact with an infected person or animal
Opportunistic infections in AIDS patients
Enterobius vermicularis or pinworm
Cellophane tape prep
Ingestion of infected food Contaminated hands Soiled clothing or bedding Most common in children
Anal itching and irritation
Plasmodium (malarial parasite)
Blood
Bite of infected anopheles mosquito
Malaria
MICROBIOLOGY
also decreased and the yeast can proliferate, causing an infection. The pathogenic Candida species is the common fungus responsible for vaginal yeast infections. Many yeast infections are often superficial and the causative agent can be identified by culturing and examining skin scrapings and hair and nail clippings. The fungi that cause skin, hair, and nail infections are classified as dermatophytes. Both yeasts and molds have specific identifying characteristics that can be viewed in Figure 29-20. Molds produce a characteristic branching filament known as hyphae and reproduce by forming spores. Yeasts appear in an egg-shaped unicellular form and reproduce by a process known as budding.
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Yeasts can be identified by microscopic observation and biochemical reactions. Molds are identified by both macroscopic observation of their growth and microscopic examination for morphology and spores. Molds are known to produce aerosols and should be examined under a safety hood.
KOH Prep A test known as the KOH (potassium hydroxide) prep is used to identify certain fungi. The reagent potassium hydroxide is added to the specimen on a slide to clear away cellular debris. This makes the fungal characteristics, such as hyphae and spores, more visible microscopically. Table 29-9 lists some common fungi and the conditions they cause.
QUALITY CONTROL FIGURE 29-20 Identifying characteristics of yeasts and molds: (a) mold-producing hyphae, (b) budding yeast
Quality control must be performed in every department of the laboratory, including microbiology. Specimens and equipment must be properly checked and maintained. Reagents and media need to have quality
TOOL BOX
C R I T I C A L T H I N K I NG CHALLENGE
(a)
A patient comes in complaining of vaginal symptoms. The patient states that she has lots of vaginal itching and a whitish mucous discharge coming from the area. 1. What are some likely tests that the provider may want to perform based on the patient’s symptoms?
(b)
TABLE 29-9 Common Fungi FUNGI
DISEASE/CONDITION
Histoplasma capsulatum
Histoplasmosis
Coccidioides immitus
Coccidioidomycosis (Valley fever)
Tinea species
Dermatomycosis (ringworm)
Candida
Candidiasis Vaginal infections Thrush
Aspergillus and Cryptococcus
Systemic infections in immunocompromised patients
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control checks as well. The following guidelines are suggested as part of microbiology quality control: ❖ Microscopes must be cleaned and maintained in proper working order. ❖ Refrigerators and incubators must be checked daily for proper temperature levels, and a log must be maintained listing the daily readings (Figure 29-21).
❖ Culture media must be stored properly and must not be used past the expiration date. ❖ A positive and negative control must be performed with each test kit and the results entered and maintained in a quality control log. ❖ Proficiency testing should be performed according to the level of the laboratory.
FIGURE 29-21 A quality control log documenting daily temperature readings
LABORATORY TEMPERATURE LOG DATE
EQUIPMENT
TEMPERATURE
INITIALS
READING
12-02-XX 12-02-XX
refrigerator incubator
4ºC 37ºC
lmv lmv
MICROBIOLOGY
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PROCEDURE 29-1 Prepare a Urine Specimen for Culture and Sensitivity Using a Urine Transport System Objective: To prepare a urine specimen using a urine transport system to be sent to a lab for a culture and sensitivity test.
Equipment/Supplies: ❖ ❖ ❖ ❖ ❖
Urine transport system Urine specimen in sterile container Gloves Lab requisition Patient’s chart
PROCEDURAL STEPS
RATIONALE
1. Wash your hands and apply gloves and the appropriate PPE. Check the provider’s order and complete the lab requisition form. Label the transport tubes.
PPE protects you from possible contamination and exposure to pathogenic organisms contained in the specimen. Checking the provider’s order while completing the lab requisition helps to assure that you order the correct tests.
2. Assemble the equipment.
Having all the needed equipment ready before beginning prevents delays due to missing equipment.
3. Check the expiration date on the transport system before beginning the transfer. Make sure the urine specimen is properly labeled.
Never use a transport system that has expired, because the integrity of the specimen cannot be guaranteed.
4. Open the urine transport kit (Figure 29-22a) and assemble it according to the manufacturer’s directions. Insert the urine tube into the holder without piercing the stopper (Figure 29-22b).
Following the manufacturer’s directions will ensure proper usage of the kit. Piercing the stopper before the unit is in the urine can destroy the vacuum.
5. Open the urine specimen and place the lid upsidedown on the work surface.
Placing the lid upside-down prevents the inside of the lid from becoming contaminated
FIGURE 29-22a Components of a urine culture and sensitivity transport system
FIGURE 29-22b Insert the vacuum tube into the holder but do not push the tube onto the needle. continues
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continued
PROCEDURAL STEPS
RATIONALE
6. Put the straw of the transport system into the urine specimen and push the vacuum tube onto the needle inside the tube holder (Figure 29-23).
Pushing the vacuum tube onto the needle will allow the vacuum in the tube to draw the urine in automatically.
7. Allow the tube to fill completely (Figure 29-24).
Allowing the tube to fill completely will provide the lab with an adequate amount of specimen.
8. Remove the tube from the holder and properly dispose of the unit.
The transport unit contains a body fluid and must be disposed of according to OSHA guidelines.
9. Clean and disinfect the work area and dispose of contaminated supplies.
Every surface must be disinfected after working with a body fluid specimen to prevent contamination to others.
10. Remove PPE and wash your hands.
Hands must be washed after removing gloves.
11. Document the procedure in the patient’s chart.
Documentation is proof of completion of the procedure and confirms to which laboratory the specimen was sent.
DOCUMENTATION EXAMPLE:
10-10-XX 11:00 a.m.
Sent sterile urine specimen for C & S per Dr. Anderson, to Lab of America. Lillian Karnes, CMA (AAMA)
FIGURE 29-23 Insert the straw into the urine specimen. Make sure the tip of the straw is completely submerged in the urine.
FIGURE 29-24 Push the tube onto the needle and allow the vacuum to automatically pull the urine into the tube.
MICROBIOLOGY
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PROCEDURE 29-2 Collect a Throat Specimen and Perform a Rapid Strep Test Objective: To collect a specimen from the pharynx and tonsillar area to be used when performing a rapid strep test or a culture.
Equipment/Supplies: ❖ ❖ ❖ ❖ ❖
Gloves Gown Face shield Tongue depressor Sterile swabs
PROCEDURAL STEPS
❖ Culture collection system (Culturette) ❖ Patient’s chart RATIONALE
1. Assemble the equipment and check the order.
Always have the needed equipment ready before beginning the collection to avoid delays in the procedure.
2. Wash your hands and apply PPE.
PPE protects you from possible contamination or exposure to a pathogenic organism during collection.
3. Identify the patient using at least two identifiers, identify yourself, and explain the procedure.
Always be sure the specimen is collected from the correct patient.
4. Adjust the light source so the throat is clearly visible.
The entire throat must be clearly visible in order to see the proper area for collection.
5. Instruct the patient to stick out the tongue and say “Ahhhh” while depressing the tongue with the tongue depressor (Figure 29-25).
Holding the tongue down with the tongue depressor keeps it out of the way and makes the area of the throat to be swabbed more visible.
6. Roll the swab against the back of the throat and the tonsillar area, being sure to swab any reddened areas or pustules.
Rolling the swab over inflamed areas ensures maximum coverage of the swab with material from areas where pathogens may be present.
7. While still holding the tongue down, carefully withdraw the swab from the mouth being sure not to touch the sides of the mouth or the tongue.
Touching the swab to the sides of the mouth or the tongue will contaminate the swab with normal flora that may interfere with test results.
FIGURE 29-25 The medical assistant swabs the sides of the throat, avoiding the tongue and cheeks.
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PROCEDURAL STEPS
RATIONALE
8. If sending the specimen to the lab for a culture, the swab must be placed in appropriate transport media (Figure 29-26) and must be accompanied by a lab requisition form (Figure 29-27). If performing a rapid strep test, follow the manufacturer’s directions.
If sending the specimen to the lab for a culture, the swab is placed in transport media to prevent the specimen from drying.
9. Properly dispose of used equipment.
Proper disposal of contaminated articles will help to prevent cross-contamination.
FIGURE 29-26
10. Remove PPE and wash your hands.
Washing your hands after a procedure helps to prevent self- and cross-contamination.
11. Document the procedure in the patient’s chart.
Always document specimen collection in the patient’s chart, even if the specimen is not tested in the POL.
After collecting the specimen, the medical assistant places the swab into the transport media to protect it from drying out.
DOCUMENTATION EXAMPLE:
04-22-XX 12:30 p.m.
Collected throat swab for C & S per Dr. Samuel’s orders. Sent specimen to Qwest labs for testing. Chris Leonard, RMA
FIGURE 29-27 The medical assistant completes the lab requisition form that will accompany the specimen to the lab.
PROCEDURE 29-3 Collect a Wound Specimen Objective: To collect a specimen free from normal flora and from deep within the wound to ensure accurate culture results.
Equipment/Supplies: ❖ ❖ ❖ ❖ ❖
Disposable gloves/sterile gloves Gown Face shield Skin antiseptic Sterile drapes/bandaging supplies
PROCEDURAL STEPS 1. Assemble the equipment, wash your hands, and apply PPE.
❖ Sterile swabs ❖ Appropriate transport media ❖ Patient’s chart RATIONALE Apply PPE before beginning specimen collection to prevent self-contamination.
Copyright 2009 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
MICROBIOLOGY
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RATIONALE
2. Check the provider’s order and complete lab requisition form.
Checking the order ensures that you are ordering the correct test.
3. Identify the patient using at least two identifiers, identify yourself, and explain the procedure.
Patients are sometimes more cooperative if they know what to expect.
4. Wash your hands, set up a sterile tray, and drape the patient. Wash your hands again and apply sterile gloves.
Because this is an open wound, sterile technique must be followed to prevent infection.
5. If the specimen will be collected from an abscess, apply an antiseptic to the affected area. Avoid contaminating the specimen with normal flora. If the specimen is collected from the wound, clean any purulent material from the wound. Rotate the swab deep in the wound, being careful not to touch the skin when withdrawing the swab.
Applying antiseptic to the skin will help to remove normal flora from the surface, which could interfere with test results. Purulent material, found inside the wound, contains a large amount of contamination from normal flora that resides on the surface of the skin. The presence of a large amount of normal flora can interfere with test results.
6. Immediately place the swab in the appropriate transport media. Clean and dress the area according to the provider’s instructions.
The swab must be protected from drying. The swab should also be transported under anaerobic conditions, as many wound infections are caused by anaerobic microorganisms. The wound is dressed to keep out microorganisms.
7. Properly dispose of contaminated equipment.
Proper disposal of contaminated articles will help to prevent cross-contamination.
8. Remove PPE and wash your hands.
Washing your hands after a procedure helps to prevent self- and cross-contamination.
9. Document the collection procedure in the patient’s chart.
Always document specimen collection in the patient’s chart, indicating the laboratory that will be testing the specimen.
DOCUMENTATION EXAMPLE:
02-24-XX 10:10 a.m.
Collected wound culture swab from lesion on right forearm, per Dr. Leonard’s orders. Specimen sent to Qwest labs for C & S. Lilian Karnes, CMA (AAMA)
PROCEDURE 29-4 Prepare a Wet Mount or Hanging Drop Slide Objective: To prepare a slide for observation of organisms in a living state to view motility and other identifying characteristics.
Equipment/Supplies: ❖ ❖ ❖ ❖
Gloves Gown Glass slide Glass slide with concave well
❖ ❖ ❖ ❖
Cover slips Petroleum jelly Dropper Bacterial suspension
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PROCEDURAL STEPS
RATIONALE
1. Assemble the equipment and supplies.
Assembling all equipment and supplies before beginning a procedure helps to eliminate delays.
2. Wash your hands and apply PPE.
Washing your hands helps to eliminate contamination and PPE offers personal protection.
3. Wet mount slide preparation: a. Place the swab in a test tube with 0.5 mL of saline and mix well. Deposit a drop of bacterial suspension in the middle of a clean glass slide. b. Smear petroleum jelly around the edges of a clean cover slip, and place the cover slip over the drop of suspension (refer to Figure 29-17). c. Gently press the cover slip to seal the edges. Hanging drop slide preparation: a. Smear petroleum jelly around the edges of a clean cover slip and deposit a drop of bacterial suspension in the middle of the cover slip (refer to Figure 29-18a). b. Invert the slide and place the concave well over the drop of bacterial suspension (refer to Figure 29-18b). c. Gently press down on the slide to seal the edges of the cover slip. Carefully turn the slide right side–up for microscopic examination by the provider (refer to Figure 29-18c).
Suspending the bacterial specimen in a liquid, like normal saline, makes viewing easier. Sealing the edges of the cover slip with petroleum jelly prevents drying of the specimen.
Inverting the slide permits the drop to hang from the cover slip during examination. Handling the slide gently and carefully prevents the drop from dislodging.
PROCEDURE 29-5 Instruct a Patient on Fecal Specimen Collection for Ova and Parasite Testing Objective: To instruct the patient on proper collection and preservation of a fecal specimen to ensure accurate test results.
Equipment/Supplies: ❖ Printed instructions
❖ Appropriate specimen containers
PROCEDURAL STEPS
RATIONALE
1. Wash your hands and assemble the equipment.
Hands should be washed before and after each patient to prevent contamination.
2. Identify the patient using at least two identifiers, and identify yourself.
Identifying yourself may help the patient to feel more comfortable when you are speaking with the patient.
Copyright 2009 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
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RATIONALE
3. Give the patient the appropriate specimen containers and gloves and explain that the specimen will be collected at home. Patients are given small vials containing a preservative to hold an aliquot of the original specimen (Figure 29-28).
The preservative will preserve the specimen until it can be tested.
4. Instruct the patient to: a. Collect the specimen in a wide-mouthed container without contaminating the fecal specimen with urine.
Using a widemouthed container makes collection much easier. Urine FIGURE 29-28 Examples of fecal specimen vials can destroy protozoan trophozoites. Each collection system has its own specific instructions.
b. Follow the instructions on the vial for preparing the specimen. c. Collect at least three specimens on consecutive days, per the provider’s orders. d. Transfer each vial into a plastic sealable storage bag following collection. Store and return specimens according to the instructions on the lab form.
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Storage and return instructions may vary slightly from one lab to another. Some labs may want specimens refrigerated even though there is a preservative in the containers.
5. Encourage the patient to ask questions and give ample time for answers.
It is vitally important that the patient clearly understands all aspects of the collection process to ensure accurate test results.
6. Supply the patient with written instructions.
Written instructions eliminate the need to rely on memory.
7. Make sure the patient understands the collection process before leaving the office and when and where to return the specimen.
Some patients are reluctant to call the office with questions.
DOCUMENTATION EXAMPLE:
08-12-XX 2:30 p.m.
Provided instructions and appropriate containers for O & P fecal specimen collection. Pt. instructed to RTO with specimen in 3 d, per Dr. Gent’s orders. Millie Leonard, CMA (AAMA)
Chapter Summary Microbiology is a vast field of study, especially in the clinical laboratory. New organisms and viruses are constantly being discovered and these organisms must be identified in patient specimens to facilitate the implementation of proper treatment methods, including the identification of the drug of choice. Some microbiology testing may be performed in the POL; however, most microbiology specimens will be sent to outside laboratories for testing. Proper specimen collection and handling is essential for accurate identification.
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FIELD APPLICATION CHALLENGE A mother brings her 12-year-old child complaining of a fever and a severe sore throat to see the physician. After examining the patient, the physician orders a rapid strep test, which comes back negative. The physician then orders a culture and sensitivity test and asks you to collect a throat swab to be sent to the laboratory for testing.
1. Why did the physician order a culture and sensitivity after the rapid strep test was negative? 2. Will the physician treat the illness differently based on the test results?
Chapter Assessment 1. Bacteria that are normally present in the body and usually pose no health threat to the host are called: a. obligate parasites. b. microbes. c. normal flora. d. pathogens. 2. The name of the method used to grow and isolate microorganisms is: a. sensitivity testing. b. culture. c. Gram stain. d. wet mount. 3. A KOH prep is used to identify: a. viruses. b. parasites. c. rickettsiae. d. fungi. 4. Bacteria that appear round and occur in bunches are known as: a. diplococci. b. streptococci. c. staphylococci. d. cocci.
5. Culture media that supports the growth of one type of organism while inhibiting the growth of another is known as: a. basic. b. selective. c. differential. d. enriched. 6. Rod-shaped bacteria occurring in pairs are known as: a. bacilli. b. diplococci. c. streptobacilli. d. diplobacilli. 7. Bacteria that stain purple with Gram stain are classified as: a. Gram negative. b. Gram variable. c. Gram positive. d. Gram absolute. 8. To preserve a swabbed specimen after collection, it should be placed in the: a. refrigerator. b. transport media. c. sterile container. d. incubator.
MICROBIOLOGY
Web Activities 1. Visit the CDC’s Web site at http://www.cdc.gov for a great image library of microorganisms. 2. Surf the Web site of the World Health Organization at http://www.who.int for information on the newest influenza viruses and for health topics from other countries. 3. Visit http://www.idsociety.org for information on the “bird flu” pandemic.
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THE DVD LINK On your StudyWARE CD-ROM, go to the DVD Challenge for this chapter. View the DVD clip and respond to the following questions: 1. What was the purpose of using two swabs at the same time when collecting a throat specimen? 2. What areas should be avoided when swabbing a throat?
CONNECTION Using your StudyWARE CD-ROM: ❖ Complete the Hangman and Crossword Puzzle activities for this chapter. ❖ Complete the Quiz for this chapter in Test Mode.
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3. When performing the QuickVue rapid strep test, how will you know if the patient has a positive result?
C H A P T E R
Clinical Chemistry and CLIA Waived Rapid Tests Chapter Outline Clinical Chemistry Tests Quality Control Specimen Requirements Serum Plasma Whole Blood Appearance of Serum and Plasma Profiles and Panels Hepatic/Liver Profile Renal Profile Lipid Profile Cardiac Profile Thyroid Panel
Glucose Testing Fasting Blood Glucose Level Two-Hour Postprandial Blood Glucose Level Glucose Tolerance Test (GTT) Glycosylated Hemoglobin (HbA1c) Additional Chemistry Tests Serology/Immunology Tests Rapid Tests Common Serology Tests Blood Typing ABO Blood Typing Rh Blood Typing Drug Testing Chain of Custody
30 Essential Terms agglutination analyte antibody antigen antiserum bilirubin blood urea nitrogen (BUN) cholesterol high-density lipoprotein (HDL) homeostasis human chorionic gonadotropin (hCG) hyperglycemia hypoglycemia lipoprotein low-density lipoprotein (LDL) triglyceride
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KEY COMPETENCIES
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CAAHEP
ABHES
Measuring Blood Glucose Using a Handheld Monitor
III.C.3.b.1.d III.C.3.b.1.e III.C.3.b.3.c III.C.3.b.3.c.iii
VI.A.1.a.4.i VI.A.1.a.4.k VI.A.1.a.4.q VI.A.1.a.4.r
Performing a Urine Pregnancy Test
III.C.3.b.1.d III.C.3.b.1.e III.C.3.b.3.c
VI.A.1.a.4.i VI.A.1.a.4.k VI.A.1.a.4.q VI.A.1.a.4.r
Perform a CLIA Waived Mono Test
III.C.3.b.1.d III.C.3.b.1.e III.C.3.b.3.c.iv
VI.A.1.a.4.i VI.A.1.a.4.k VI.A.1.a.4.q VI.A.1.a.4.r
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Developmental Objectives After completing this chapter, you should be able to: 1. Correctly spell and define the essential terms. 2. List the normal values and clinical significance for the following tests: FBS, BUN, HbA1c, creatinine, total cholesterol, HDL, LDL, and triglycerides. 3. Explain the difference between serum and plasma. 4. Explain the importance of proper specimen collection and preservation. 5. Describe the appearance of lipemic, icteric, and hemolyzed serum and the clinical significance of each. 6. Explain what happens to chemical substances in the body when homeostasis is disrupted. 7. Define the purpose of a laboratory profile. 8. Name the electrolytes and explain their function. 9. List three tests commonly included in a thyroid panel. 10. Explain the difference between Type 1 and Type 2 diabetes. 11. Explain the purpose of the two-hour postprandial blood test. 12. Discuss the role of the HbA1c test in the management of diabetes. 13. Name the most common cause of peptic ulcer. 14. List the antigens and antibodies present in the four ABO blood types. 15. Explain chain of custody and list the steps that are taken to ensure the validity of a specimen.
Introduction The numerous analyses performed in the chemistry and serology departments comprise the bulk of all laboratory tests performed. Increased or decreased levels of certain chemical substances in the blood can be an early indicator of disease
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or serve as an evaluator of the function of a particular organ in a body system. Test results are a fast and useful tool for the physician to determine a diagnosis and implement a proper treatment plan. Several laboratory tests are often grouped together and ordered as a profile or panel, eliminating the need to order each test separately. For example, a thyroid panel, which commonly includes three separate tests— the T3, T4, and TSH—can be ordered as one profile instead of three separate tests. The tests included in a profile may vary from one lab to the next—this chapter lists the general tests included in each type of profile. The most common chemistry and CLIA waived rapid tests are addressed in this chapter along with their descriptions and normal values. Table 30-4, at the end of this chapter, lists the common clinical tests discussed along with their clinical significance, normal/reference ranges, and test rationale.
CLINICAL CHEMISTRY TESTS In a healthy body, specific mechanisms monitor and make adjustments to the internal environment to help maintain a constant state of balance known as homeostasis. When homeostasis is disrupted, the body responds by making adjustments to either lower or increase chemicals that are out of normal range. These chemical elements can be found in the blood in both health and disease. A change in the level of one of these substances can be indicative of a disease process or how well a particular treatment method is working. Any body fluid may be chemically analyzed, but this text will address specimens such as serum, plasma, urine, and whole blood. In clinical chemistry, chemical elements, or analytes, are measured by many different quantitative methods, using both countertop and handheld instruments. There are a variety of chemistry analyzers on the market that measure chemical elements in the blood. The majority of these analyzers are considered moderately complex; however, more and more medical manufacturers are developing analyzers that meet the necessary specifications to be waived by CLIA. An example of an automated blood chemistry analyzer is shown in Figure 30-1. These instruments can perform tests that are specific to a particular specialty in a short period of time.
Quality Control Quality control is performed on all types of laboratory tests, regardless of whether the test is performed manually or through automated methods. Many test
FIGURE 30-1 The Nova CCX analyzer provides chemistry profiles that include commonly ordered STAT chemistry tests. (Courtesy of Nova Biomedical, Waltham, MA.)
kits have internal and external controls to ensure the test is reading accurately, while an instrument must be calibrated using a standard to check the precision of its results. Both normal and abnormal controls should be analyzed prior to reporting patient results. If control results do not fall within the acceptable range established by the manufacturer, patient test results should be considered inaccurate and should not be reported. Any health care worker operating an analyzer must troubleshoot problems and determine if the error exists within the instrument, the reagents, or the way the procedure is being performed. All control results should be documented in a quality control log (Figure 30-2) and should be kept for the appropriate amount of time required by law.
SPECIMEN REQUIREMENTS Test results are greatly affected by the quality of the specimen that is sent to the lab. It is important to follow all guidelines for specimen collection and handling. Collection and handling techniques are addressed throughout the remainder of this chapter. Many chemistry and serology tests are performed on serum; however, other samples such as plasma, whole blood, and arterial blood may be required.
Serum Serum is the liquid portion of the blood that remains after the blood has clotted. Blood is usually collected in a serum separator tube (SST), which contains a clot activator for faster processing.
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GLUCOSE QUALITY CONTROL LOG Cholesterol Analyzer (KLM Diagnostics) Date
10-10-XX
Time
1:30 p.m.
Lot#
Type of
Reference
Control
Range
Results
852514789 High Control 300−360 mg/dl 320 mg/dl
Initials
LMV
FIGURE 30-2 An example of a quality control log sheet. Each type of control should have a separate log sheet.
After collection, the blood is allowed to sit for 20 to 30 minutes and then centrifuged. During centrifugation, the separator gel moves up the tube to form a barrier between the clot and the serum (Figure 30-3). Serum is then transferred to a properly labeled sample tube and sent to the laboratory for testing.
Plasma There are some chemistry tests that are performed on plasma. In a lab setting, plasma is the liquid portion of the blood to which an anticoagulant has been added. Blood is collected into a tube containing an appropriate anticoagulant for a particular chemistry test. Lithium heparin is usually the anticoagulant of choice, as
EDTA and sodium heparin can destroy some components being analyzed. Once the tube has been centrifuged, the plasma should be transferred to a separate sample tube and properly labeled as plasma. When placed in a sample tube, plasma and serum have the same appearance; therefore, the only way to determine the specimen type is through proper labeling.
Whole Blood A whole blood sample contains the appropriate anticoagulant and is not separated into its components. Some tests require whole arterial blood. A test known as an arterial blood gas (ABG) is one example
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TOOL BOX
C R I T I C A L T H I N K I NG CHALLENGE A test calls for 7 mL of serum. You have 3, 6, and 10 mL tubes available. 1. How many total milliliters of blood will be necessary to obtain the proper amount of serum requested? 2. What color tube tops will you use to obtain the serum? 3. What combination of tube sizes will you draw to obtain the required amount of serum?
TOOL BOX
FIGURE 30-3 An SST that has been centrifuged. The gel forms a barrier between the serum and cells.
FI E L D S M A R T S of such a test. This test is usually performed in the hospital laboratory, not the POL, and requires specialized training to obtain the sample. Arterial blood is drawn into a tube containing liquid heparin. The tube must be thoroughly mixed with the anticoagulant by gentle inversion after collection to prevent clotting and the formation of air bubbles. The specimen is then placed on ice and immediately transported to the lab for testing.
APPEARANCE OF SERUM AND PLASMA The appearance of serum and plasma should be observed after collection and processing for any signs of discoloration. Both serum and plasma are normally pale yellow in color and clear in transparency. Improper collection and some diseases may alter the appearance of the specimen. Figure 30-4 illustrates serum samples with different appearances. Table 30-1 lists possible reasons for abnormal specimen appearance.
In order to obtain the required amount of plasma or serum necessary for a particular test, you will need to draw at least 2.5 times that volume in blood. For example, a 10 mL tube of blood will yield approximately 4 mL of serum or plasma following centrifugation. So to figure out how many milliliters of blood you will need, just multiply the required volume of serum or plasma by 2.5 mL.
FIGURE 30-4 Examples of both normal and abnormal appearances of serum: (a) normal, (b) hemolyzed, (c) icteric, (d) lipemic, (e) bilirubin
PROFILES AND PANELS Instead of ordering each chemistry test individually, the provider can order a group of tests known as a profile or panel. Multiple tests are included in a profile and can be performed on a small sample of blood. A
(a)
(b)
(c)
(d)
(e)
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TABLE 30-1 Color/Appearance of Serum Specimens DESCRIPTIVE TERM
COLOR/APPEARANCE
POSSIBLE CAUSE
Hemolyzed
Pink/red
Collection error Processing error Hemolytic diseases
Lipemic
Milky or cloudy
Lipid metabolism disorders Coronary artery disease (CAD)
Icteric
Deep yellow to orange Green tint Pale/watery
Due to increased bilirubin levels, seen in liver disease Certain types of malignant disease Protein disorders Kidney disease
general chemistry profile, such as the one shown in Figure 30-5, includes tests that furnish the provider with a general overview of the patient’s state of health. General chemistry profiles include the basic metabolic panel (BMP) or the comprehensive metabolic panel (CMP). The BMP comprises seven different tests that check items such as acid/base balance and calcium levels. The CMP is more comprehensive, as its name indicates, and is comprised of 14 tests—the seven included in the BMP, plus other tests that screen par-
ticular organ functions. Chemistry profiles may also be organ-specific, such as a renal or liver profiles.
Hepatic/Liver Profile A hepatic profile can evaluate the general condition of the liver as well as assess a particular disease or disorder. Tests included in a hepatic profile will vary depending on which lab is used, but generally the following tests are included:
FIGURE 30-5 An example of a laboratory form listing different types of profiles
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❖ Total and direct bilirubin: Bilirubin is a waste product of hemoglobin breakdown formed in the liver and excreted in bile. Total and direct bilirubin look at the different types of bilirubin found throughout the body. Knowing the percentages of each type assists the provider with diagnosing particular types of liver or gallbladder disease. ❖ Total protein: This test evaluates the level of albumin and globulin in the blood and the albumin/ globulin ratio; decreased in liver disease. ❖ Alanine aminotransferase (ALT): Found in high concentrations in liver cells; increased in liver disease. ❖ Aspartate aminotransferase (AST): Found in cardiac muscle and liver cells; increased levels indicate cell damage. ❖ Lactate dehydrogenase (LDH): Found in almost all body tissues and released after tissue damage. ❖ Gamma-glutamyl transpeptidase (GGT): An enzyme found in the liver; increased in liver disease. ❖ Alkaline phosphatase (ALP): A liver enzyme; this test is performed to assist with the diagnosis of hepatic disease; also elevated in liver disease. Some laboratories also offer profiles that include tests that are specific for the different types of hepatitis. These tests detect not only the presence of the disease, but the type of hepatitis as well.
Renal Profile A renal profile can provide a rapid assessment of a patient’s general health and is, therefore, one of the most frequently requested groups of tests. This profile can also provide information about the progression of kidney disease and complications that may arise due to other conditions, such as diabetes mellitus. Tests included in a renal profile can furnish the provider with important diagnostic information. The following analytes are usually included in a renal profile because the kidney helps to keep these chemicals in balance through processes known as filtration, reabsorption, and secretion. Abnormal levels of these analytes may indicate kidney disease: ❖ Sodium: This substance is vital to life and helps to control the acid-base balance in the body, along with transmitting nerve impulses. It also indirectly regulates water levels in the body. ❖ Potassium: This analyte affects the acid-base balance and aids in the reactions that take place during carbohydrate and protein metabolism. Potassium also has a significant influence in con-
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ducting electrical impulses in heart and skeletal muscles. Chloride: Chloride maintains water and acid-base balance in the body. (Note: Sodium, potassium, and chloride [Na, K+, and Cl] can be grouped together and requested as an electrolyte panel.) Blood urea nitrogen (BUN): This test measures the nitrogen portion of urea, which is the end product of protein metabolism. This compound should be excreted by the kidneys, so an elevation of this waste product in the bloodstream is a good indictor of the excretory function of the kidneys. Creatinine: A byproduct of muscle metabolism that is normally excreted by the kidneys. This test is a good indicator of kidney function. Uric acid: Also an end product of the breakdown of protein that should be excreted by the kidneys. CO2: Carbon dioxide in the blood comes from bicarbonate, which is regulated by the kidneys. CO2 is often included in an electrolyte panel and is also a blood gas. A decreased level could indicate renal failure. Glucose: Increased levels of glucose can be a sign of chronic renal failure.
Lipid Profile Increased lipids or fats in the blood can be an indicator of an increased risk of developing heart disease. Cholesterol and triglycerides are the lipids generally found in the blood. When cholesterol is combined with protein in the blood it is termed as a lipoprotein. Cholesterol is important in order for many life functions to take place, such as the synthesis of steroid hormones. Although the body easily produces cholesterol, it is not easily broken down and may build up in different tissues, especially the blood vessels. If this buildup occurs, a condition known as athersclerosis may develop, which places the patient at a higher risk of heart attack. Because the body produces enough cholesterol to meet its needs, dietary intake is not usually necessary. When evaluating the level of lipids in the blood, a total cholesterol level is determined. Additionally, the cholesterol level is divided into high-density lipoprotein or HDL (“good” cholesterol) and low-density lipoprotein or LDL (“bad” cholesterol). HDL is the lipoprotein that removes cholesterol from the body by taking it to the liver, where it is excreted in bile. LDL is deposited as fat in the tissues of the body and in the walls of the blood vessels, which increases the risk of coronary artery disease.
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F IEL D S M A R T S Food consumption can have a direct impact on cholesterol levels. Be sure to verify that your patient has fasted a minimum of 8 to 12 hours prior to testing (this requirement will vary by lab). Some providers will also ask patients to participate in a low-fat diet for a specified number of days prior to testing.
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P ATIEN T TU T OR It is possible to decrease the level of LDL or “bad” cholesterol in the blood and at the same time raise the level of HDL or “good” cholesterol in the blood. A combination of weight loss, exercise, a diet low in saturated fats, and smoking cessation can accomplish this goal. Consumption of foods with polyunsaturated fats, like corn, safflower, and many fish oils, in place of foods high in saturated fat can also lower blood cholesterol levels.
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CR ITI C A L TH I N K I N G C H AL LEN G E After drawing blood from a patient for a lipid profile, you dismiss the patient and begin to complete the lab requisition form. Suddenly, you realize that you forgot to ask the patient if she was fasting. 1. What are your options? 2. How could this have been prevented? 3. Will you still be able to send the sample to the lab?
Triglycerides are another type of lipid or fat found in the blood. While these fats are a source of energy, if present in increased amounts they are stored in the body as adipose tissue. Elevated triglyceride levels can increase a patient’s risk of developing cardiovascular disease. The tests in a lipid profile may include:
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❖ Total cholesterol: The total of all types of cholesterol. ❖ HDL: Increased levels of “good” cholesterol can decrease the risk of coronary artery disease. ❖ LDL: Increased levels of “bad” cholesterol are strongly associated with coronary artery disease. ❖ Triglycerides: Increased levels may be associated with coronary heart disease (CHD). CLIA waived portable lipid testing systems, such as the one pictured in Figure 30-6, are now available for use in the medical office. The LDX System® by Cholestech can complete a lipid panel plus a glucose determination in just five minutes. Testing by this method requires only a small drop of blood, which can be obtained by capillary puncture. This system meets guidelines of the National Cholesterol Education Program (NCEP) for precision and accuracy, and is certified accurate by the CDC's Cholesterol Reference Method Laboratory (CRMLN) for total and HDL cholesterol. It also provides an ALT and AST test to monitor liver function and determine possible side effects of cholesterol-lowering or diabetes medications. HS-CRP testing is also available with the Cholestech LDX system for moderate complexity labs.
Cardiac Profile A cardiac profile includes tests that determine the levels of cardiac enzymes in the blood. The levels of these enzymes increase when tissue damage occurs as a result of trauma, ischemia (a temporary decrease of blood flow to a body part), or an acid-base imbalance. Levels of cardiac enzymes are increased both during and following a myocardial infarction. Tests commonly included in a cardiac profile are: ❖ LDH: Elevated levels could indicate heart damage. This enzyme is found not only in the heart, but in the liver, kidneys, and skeletal muscles as well.
FIGURE 30-6 Cholestech LDX system, which provides a full lipid profile, glucose, or ALT-AST (Courtesy of Cholestech Corporation.)
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Further testing is required to determine the location of tissue damage when increased levels of LDH are detected. ❖ Creatine phosphokinase (CPK): This enzyme is found in cardiac muscle, skeletal muscle, and brain tissue. CPK is made up of three separate components or isoenzymes. If the CPK level is increased, further testing is required to determine which of the isoenzymes is elevated. The CPK-MB isoenzyme is a specific indicator of heart muscle cell damage. ❖ AST: AST is an enzyme found primarily in cardiac muscle and the liver. Moderate amounts may also be found in the kidneys, pancreas, and skeletal muscle. High levels are found after an acute myocardial infarction.
Thyroid Panel A thyroid panel is often ordered to evaluate the function of the thyroid gland. The thyroid gland (an endocrine gland) is important because of the role it plays in metabolism. T3 (triiodothyronine) and T4 (thyroxine) are the two hormones produced by the thyroid gland that affect metabolism. A third horomone, thyrocalcitonin, stimulates calcium to be stored in the bones. Iodine is necessary for the thyroid gland to produce these hormones and can be obtained from seafood, iodized salt, or by consuming vegetables grown in soil containing iodine. The tests included in a thyroid panel may vary by laboratory, but usually include: ❖ T3: Levels of this thyroid hormone, along with T4, are helpful in diagnosing hyper/hypothyroidism. ❖ T4: Also known as “Total T4”; is usually performed in conjunction with T3. This test is also helpful in diagnosing hyper/hypothyroidism.
❖ Thyroid stimulating hormone (TSH): This hormone is secreted by the pituitary gland and is responsible for signaling the thyroid gland to secrete more T3 and T4 when levels are deficient. If these three tests are abnormal, more specific thyroid tests are available for a definitive diagnosis.
GLUCOSE TESTING Glucose is the cells’ primary source of energy; it must stay within a particular range, or complications will arise. Excess glucose is transformed into glycogen, which is then stored in muscle and the liver tissue for future use. If glucose levels in the blood diminish, the liver converts glycogen back into glucose so that it can be used by cells for energy. If the tissues can no longer hold the excess glucose, the glucose is converted to fat and stored in the form of adipose tissue. Glucose can not enter cells without the hormone insulin. Insulin is secreted by the beta cells of the pancreas and is the key that unlocks the door for the glucose to enter the cell. If insulin is not being produced, or the patient has a condition known as insulin resistance, glucose is unable to get in the cell and the body will use other sources of energy such as fats and proteins to feed the cell. The increased levels of glucose will build up in the blood stream, causing an array of problems for organs such as the heart and kidneys. By measuring the level of glucose in the blood, problems with carbohydrate metabolism, such as diabetes, may be detected, along with hypoglycemia, or low blood sugar. The most likely cause for an increase in blood glucose levels (or hyperglycemia) other than diabetes may be pancreatitis or chronic renal failure. Refer to Table 30-2 for a description of the different types of diabetes.
TABLE 30-2 Types of Diabetes CLASSIFICATION
GENERAL FACTS
Type-1 (also known as insulin-dependent or juvenile-onset)
Usually diagnosed before age 25 Patients require insulin therapy.
Type-2 (or adult onset)
Usually occurs after the age of 40 Can be controlled with diet, exercise, and oral hypoglycemics Patients occasionally need insulin therapy.
Gestational
Diabetes mellitus begins during pregnancy, usually in the second or third trimester. Usually subsides after delivery, but a third of women with this type of diabetes will eventually develop Type-2 diabetes.
PAT I E N T T U T O R Diabetes is a chronic disease that will be with the patient for the rest of the patient’s life. Diabetic patients should understand that the disease can be controlled through lifestyle changes. These patients are often sent to a dietician following diagnosis of the disease. The dietician develops a food plan that helps the patient know what the patient can eat and how often to eat. Along with modifications in diet, patients should be encouraged to start a regular exercise routine and may
Blood glucose levels can be measured by several different test methods, including the fasting blood sugar (FBS), the two-hour postprandial blood glucose (2 HPP), and the glucose tolerance test (GTT). Blood glucose determination is one of the most common chemistry tests performed in the laboratory. Patients can also monitor their blood glucose levels at home. Numerous models of handheld glucose monitors are available for use. Figure 30-7 illustrates a few different types of glucometers. Many of the newer monitors only require a tiny drop of blood for testing and may be obtained from the palm of the hand, upper arm, forearm, thigh, and calf instead of the fingertips. Procedure 30-1 outlines the method involved in measuring a blood glucose level using a handheld monitor.
Fasting Blood Glucose Level Since diet can affect the amount of glucose in the blood, screening levels are usually measured when a patient is fasting. To be in a fasting state, the patient must not eat or drink anything (except water) for 8 to 12 hours
FIGURE 30-7 Examples of different blood glucose monitors and lancing devices
need to start on one or more glucose-lowering medications. Education about the importance of regular glucose monitoring at home is another important component of diabetic education. Regular monitoring alerts the patient when glucose is in an unacceptable range and allows the patient to make appropriate adjustments before problems occur. Good patient education often stimulates good patient compliance, resulting in better health for the patient.
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prior to testing. Some medications can affect the accuracy of test results. The physician should be consulted regarding medications prior to the delivery of fasting instructions. A fasting specimen is usually obtained in the morning so the patient doesn’t have to go without food for a prolonged period of time. If the fasting blood glucose level is increased, further testing is usually recommended to determine the exact cause.
Two-Hour Postprandial Blood Glucose Level The two-hour postprandial (2 HPP) blood glucose level may also be used to screen for diabetes mellitus and is also used to determine insulin dosage. A 2 HPP glucose measures the blood glucose level two hours after the patient ingests a high-carbohydrate meal, or in place of the meal the patient may be asked to drink a glucose solution. The patient should be in a fasting state before the meal is ingested or the glucose liquid is consumed. Two hours following consumption of the meal or liquid glucose, the patient is asked to return to the office for the testing. Most providers believe that the 2 HPP glucose level is the most critical of all glucose tests. In a nondiabetic patient, the glucose level should return to normal within two hours. A level of 140mg/dL is indicative of diabetes mellitus.
Glucose Tolerance Test (GTT) A glucose tolerence test may be requested following an elevated blood glucose result or 2 HPP blood glucose result. During GTT testing, blood and urine samples are collected from the patient at specified intervals. The glucose level of the blood is determined and the urine is tested for the presence of glucose.
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The following are tips regarding the administration of a glucose supplement. ❖ You should never administer the glucose supplement until a fasting specimen is obtained and tested. If the fasting specimen is high, the provider should be alerted to determine if the glucose supplement should be administered. ❖ Chilling the glucose supplement before administering will make it easier to drink.
For three days prior to testing, the patient is instructed to eat a diet high in carbohydrates. The patient is then instructed to fast for 10 hours prior to testing. Some providers will also ask the patient to refrain from smoking and strenuous activity during the fasting period, as these activities can also affect blood glucose level. After collection of a fasting blood and urine sample, the patient is given either a dose that is calculated by body weight or the standard adult dose of 100 grams of liquid glucose. Both blood and urine samples are collected at a half hour, one hour, two hours, and three hours following the ingestion of the glucose drink. Occasionally, the test is extended and samples are collected at the fourth and fifth hours as well. The patient may consume water during the test, but nothing else. The patient may experience the normal side effects of weakness, perspiration, and feeling faint during the
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P ATIEN T TU T OR Patients who are scheduled to have a GTT should be instructed to bring a large container of water with them. Drinking water throughout the procedure will assist the patient with providing urine samples during testing. You may also encourage patients to bring reading materials or a laptop with ear plugs so that they can watch movies during the testing period. Keeping busy will help the time to pass much more quickly.
❖ The sugary glucose supplement may be hard to get down. Finding a flavor that the patient likes will aid in helping the patient to keep the glucose down once it has been ingested. ❖ If the patient throws up, the test will need to be stopped and the patient will need to be rescheduled for a new test.
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F IELD SM A RTS
second or third hour of the test; this is typically the time period that the glucose bottoms out. Reassure the patient that this is normal and should pass. If the patient exhibits prolonged symptoms of severe hypoglycemia, the provider should be alerted immediately. Symptoms of hypoglycemia may include: ❖ ❖ ❖ ❖ ❖ ❖ ❖
Headache Senseless speech Irrational behavior Cold, clammy skin Paleness Profuse sweating Fainting
Translating GTT Results During a GTT, a nondiabetic patient’s glucose level will peak at around 160 to 180 mg/dL about 30 to 60 minutes after ingesting the glucose load, and will return to the fasting level two to three hours following consumption. A patient with diabetes will have glucose levels that peak at a higher level and remain elevated throughout the test. The diabetic patient will also test positive for glucose during the urine portion of the testing. A GTT is not necessary for diagnosing diabetes in patients with a fasting blood glucose greater than 140 mg/dL or a 2 HPP glucose level greater than 180 mg/dL.
Glycosylated Hemoglobin (HbA1c) Approximately 98% of normal adult hemoglobin is HbA. A subgroup known as HbA1c is formed when glucose and hemoglobin bind together. HbA1c, or glycosylated hemoglobin, aids in determining how well blood glucose levels have been controlled over the past 8 to 12 weeks, because the life span of an RBC can be
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up to 120 days. The information gained from this test will tell the provider how diligent the diabetic patient has been about adhering to the prescribed diet and medication regimen, or the overall effectiveness of the treatment plan. HbA1c testing can now be performed in the medical office using an analyzer like the DCA 2000+® by Bayer (Figure 30-8). This CLIA waived analyzer utilizes a simple three-step procedure and requires only a small sample of blood, with results available in six minutes. The DCA 2000+ can also provide a microalbumin/creatinine result in seven minutes, which helps to detect diabetic nephropathy in its early stages. This simple in-office testing furnishes the provider with fast results while the patient is still in the office. This allows the physician to make the appropriate adjustments in the patient’s medication from the point of care.
FIGURE 30-8 DCA 2000+ by Bayer, which performs a HbA1c within six minutes (Courtesy Bayer Healthcare Diagnostics Division, Norwood, MA.)
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C R I T I C A L T H I N K I NG CHALLENGE Mr. Brown’s fasting blood glucose was in the normal range today; however, when his HbA1c results came back, they were highly elevated. 1. List two different theories as to why the results may not match.
ADDITIONAL CHEMISTRY TESTS There are hundreds of chemistry tests performed in the laboratory. Many of the common tests were discussed in the profile section of this chapter. The medical assistant needs to have a basic knowledge of other common tests as well, including:
E M R A P P L I C AT I O N Many paper charts contain a section referred to as flow sheets. These flow sheets map results of like tests over a period of time. Glucose testing is a common test that is measured on a flow sheet. The EMR contains electronic flow sheets that can be displayed in a variety of ways: ❖ They can display all lab test results performed over a period of time.
❖ They can display just abnormal test results over a specific period of time. ❖ They can appear in a graphing format. All of these choices give the provider a better look into the patient’s disease and assist the physician with medication management.
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❖ Magnesium (Mg): Magnesium is a mineral that is widely distributed in foods such as whole grains, fruits, and vegetables. It is found in soft tissue, bones, muscles, and body fluids. Increased levels are not common, but can occur in patients with chronic diarrhea or malabsorption disorders. Severe muscle spasms, weakness, and mental depression can result from decreased magnesium levels. Muscle weakness, decreased blood pressure, and bradycardia may occur with increased levels. Certain medications can interfere with test results. ❖ Phosphorous: A nonmetallic element contained in bone and skeletal muscles. Levels are controlled by the parathyroid hormone and calcium
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metabolism. Phosphorous contributes to the acid-base balance, glucose and lipid metabolism, and osteogenesis. Increased levels are most often caused by renal failure, while decreased levels may be found in different disease states and with the administration of diuretics. Calcium (Ca): This is the most abundant mineral in the body. Ninety percent of calcium is found in the bones and teeth. It is essential to cellular fluid exchange, blood clotting, regulation of the heartbeat, and bone formation. Increased levels are present in diseases such as metastatic cancer, multiple myeloma, and dehydration. Decreased levels can be found in alcoholism, acute pancreatitis, and malnutrition. Alkaline phosphatases (ALPs): This is a group of enzymes found in the liver, gall bladder, intestines, and bones. This test is ordered to help with the diagnosis of hepatic and bone diseases. Increased levels are present in liver cancer, cirrhosis, biliary obstruction, and bone infections. Decreased levels may be present in malnutrition, congestive heart failure, and pernicious anemia. Amylase: An enzyme responsible for the breakdown of starches and sugars, produced primarily in the pancreas. Increased levels are seen in pancreatitis, bile stones, or obstruction, and decreased levels may be found in hepatitis, cirrhosis, and liver cancer. Lipase: This enzyme is responsible for fat digestion and the breakdown of triglycerides. It is secreted into the blood when there is damage to the pancreas. Levels can be increased in acute pancreatitis and pancreatic cancer, acute cholecystitis, and early renal failure. Decreased levels can be found in chronic pancreatitis, viral hepatitis, and cystic fibrosis. Carcinoembryonic antigen (CEA): A tumor marker present in certain types of cancer, such as colorectal cancer. Prostate specific antigen (PSA): This marker determines the amount of an enzyme produced by the prostate gland and indicates possible prostate cancer. It can also be increased in benign prostatic hypertrophy, prostatitis, and osteoporosis.
SEROLOGY/IMMUNOLOGY TESTS Tests performed under the heading of serology and immunology evaluate antigen-antibody reactions and the body’s immune response. Analyses performed in
this area include detecting the presence of antibodies to bacteria and viruses, discovering antibody production against one’s own body (autoimmune), diagnosis of diseases like AIDS and infectious mononucleosis, and determining the presence of an antigenic substances (substances that stimulate an antibody response) such as the ABO antigens. Many rapid tests fall into this category.
Rapid Tests Commercially prepared rapid test kits are available for use at home and in the medical office. Examples of rapid tests include a test to detect infectious mononucleosis and pregnancy.
Pregnancy Tests Pregnancy testing may be performed in the medical office on urine. The presence of the hormone human chorionic gonadotropin (hCG), released by the placenta, may be detectable in the patient’s sample as early as one to five days after the first missed menstrual cycle. Many urine test kits are now available for home use. The rapid kit featured in this text is the QuickVue® by Quidel (Figure 30-9). This test is easy to perform and read, and results are ready within three minutes. Each test features a built-in control, as do most kits, to ensure test accuracy; however, external controls may also be used. Refer to Procedure 30-2 for an explanation of how to perform a urine pregnancy test. Many pregnancy test kits are available from different manufacturers. FIGURE 30-9 QuickVue One-Step hCG test by Quidel (Courtesy of the Quidel Corporation.)
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Mono Test Mononucleosis is a contagious disease caused by the Epstein-Barr virus. Infectious mononucleosis develops most often in children and young adults 15 to 25 years of age. Symptoms often begin with a fever, swollen lymph nodes, and fatigue, and can last as long as two to four weeks. The QuickVue+ Mononucleosis test by Quidel is one of several rapid tests available for use in the medical office (Figure 30-10). It is simple to perform and highly accurate. This test produces results in as little as three minutes. Some kits are not CLIA waived because they require testing to be performed on serum or plasma. (Remember that in order for a test kit to be waived by CLIA, it has to be performed on whole blood.) Refer to Procedure 30-3 for instructions on performing a mono test.
Other Rapid Test Kits New test kits are constantly being developed for use in the medical office and laboratory. Many of these rapid kits are CLIA waived and testing can be performed by the medical assistant. Rapid results can give the physician an immediate diagnosis, and treatment can begin before the patient leaves the office. Quidel has developed a new rapid test for the detection of influenza (Figure 30-11). Flu symptoms are very FIGURE 30-10 (a) QuickVue+ Infectious Mononucleosis test; (b) The top reacton windows show two positive reactions; the bottom left shows a negative reaction; the bottom right shows an invalid test result. (Courtesy of the Quidel Corporation.)
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vague and can mimick other types of viruses or infections, making it difficult to diagnose. Approximately a third of all respiratory infections are caused by influenza. By performing a rapid test, the physician can have results within 10 minutes and can begin treatment immediately. Another rapid test kit is the QuickVue One-Step H. pylori Test®. This test detects the presence of the Helicobacter pylori bacteria, which is the most common cause of peptic ulcers. The provider can now test patients in the office without the need for a more invasive procedure and a positive result can be obtained within 10 minutes from a simple finger stick. With quick inhouse results, treatment can begin immediately.
Common Serology Tests Common serology tests include: ❖ VDRL or RPR: Screening tests for syphilis. A positive test requires further testing to confirm a diagnosis.
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C R I T I C A L T H I N K I NG CHALLENGE After performing a mono test, you realize that you forgot to run an external control along with the test, and you just used the last test in the box. The internal control was positive for a reaction. 1. Should you report the results? Why or why not?
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FI E L D S M A R T S Once your body produces an antibody to a particular antigen, you will always have antibodies stored in your bloodstream to fight that antigen. Therefore, patients who test positive for mononucleosis will continue to test positive during future testing. In order to determine if the patient has active mononucleosis, the patient will need to have a titer performed that will not only determine the presence of the antibody but the amount of antibodies present in the bloodstream.
(a)
(b)
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RESULTS
Nasal swab procedure:
STRONG POSITIVE
QUI QUI
3X
INFLUENZA
REAGENT
+ 3X
WEAK POSITIVE
10
QUI QUI
+ _
NEGATIVE
QUI QUI INVALID
QUI QUI NO RESULT
QUI QUI
TEST
REAGENT
FOAM SWAB
TEST STRIP
RESULTS
Nasal wash /nasal aspirate procedure:
STRONG POSITIVE
QUI QUI
INFLUENZA
+
WEAK POSITIVE
10
QUI QUI
+ _
NEGATIVE
QUI QUI INVALID
QUI QUI
FIGURE 30-11 CLIA
NO RESULT
TEST
DROPPER
❖ HIV test: Determines the presence of the HIV virus, which causes AIDS. This test is only indicative of HIV infection and not a definitive diagnosis of AIDS. ❖ C-Reactive Protein (CRP): Determines the presence of an abnormal protein that is released into the bloodstream as a result of tissue destruction and inflammation. Since CRP is undetectable in the blood of healthy individuals, this test is useful in diagnosing rheumatoid arthritis, bacterial infections, metastatic malignancies, and acute rheumatic fever. The CRP test may also be used to track the progression of a condition and its response to medications.
QUI QUI
TEST STRIP
❖ Rheumatoid factor (RF or RA): The rheumatoid factor is an antibody present in the blood of individuals with rheumatoid arthritis, a chronic inflammatory arthritis that affects the joints. The RA test is an early diagnostic tool for rheumatoid arthritis and other autoimmune disorders that enables the physician to institute early treatment that can inhibit the progression of the disease. ❖ Antistreptolysin O titer (ASO): Diagnoses strep infections and illnesses by detecting the ASO antibody in the patient’s serum. Rising titers, over a period of time, are indicative of infection rather than a single positive test. This test is useful in diagnosing scarlet fever, acute glomerulonephritis, pneumonia, and acute rheumatic fever.
PAT I E N T T U T O R Recent research has determined that nearly 65% of all peptic or stomach ulcers are caused by the bacteria Helicobacter pylori. A rapid H. pylori test can confirm this within minutes, enabling the physician to prescribe immediate treatment for the patient. Treatment is generally in the form
of antibiotics instead of proton pump inhibitors or antacids that are typically used to treat ulcer symptoms. Once the bacteria is eliminated, the ulcer heals and there is no need for further treatment.
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waived QuickVue influenza test by Quidel (Courtesy of the Quidel Corporation.)
PAT I E N T T U T O R Patients diagnosed with rheumatoid arthritis (RA) should be informed that this disease is a systemic disease that affects the entire body. Multiple joints can be affected, but most often the synovial joints of the hands, wrists, elbows, and knees are affected. Joint pain and morning stiffness are common complaints. RA is now
BLOOD TYPING Every individual has what is known as an ABO and Rh blood type. The red blood cells have a specific protein or antigen attached to their surface that determines which ABO blood type an individual has. When typing blood, the antigen on the red blood cells reacts with an antibody in a test serum, causing a reaction known as agglutination. Agglutination occurs when the antibody in a typing serum attaches to the antigen on the red blood cells and causes a clumping reaction. When typing a patient’s blood, commercially prepared antiserum is mixed with whole blood and observed for agglutination. Anti-A antiserum contains the “A” antibody and Anti-B antiserum contains the “B” antibody. Figure 30-12 illustrates the different reactions that may occur during testing. For example, a patient’s blood that is type A will demonstrate clumping when mixed with Anti-A typing serum because the antibodies in the test serum attach to the “A” antigens on the red blood cells and cause clumping. A patient with type B blood will react with Anti-B test serum. If the patient has type AB blood, then the patient’s cells will clump when mixed with both Anti-A and Anti-B test serum. Since red cells in type O blood have no antigens, there will be no clumping reaction when type O blood is mixed with Anti-A or Anti-B test serum. Blood typing plays a critical role when transfusing blood and blood products and when performing organ transplants. For example, a person with one type of blood will have antibodies against another blood type. If the incompatible blood type is transfused, the antibodies of the recipient will react with the antigens on the donor cells and destroy them, causing a lifethreatening reaction to occur. ABO and Rh typing does not guarantee that a reaction will not take place. There are many subgroups that can cause mild reactions to occur.
being treated with a new class of drugs known as DMARDs (disease-modifying antirheumatic drugs), which work by suppressing the body’s immune and inflammatory responses. However, patients should be informed that it may take several months before the affects of the medication are realized.
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FIGURE 30-12 Agglutination reactions that occur during ABO blood typing
ANTI–A SERUM
ANTI–B SERUM
Red blood cells to be tested
ANTI–B
ANTI–A
Type O No agglutination
No agglutination
Type A Agglutination
No agglutination
Type B No agglutination
Agglutination
Type AB Agglutination
Agglutination
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ABO Blood Typing Two major antigens, A and B, can be present on the red blood cells. The presence or absence of these antigens determines an individual’s ABO blood type. The four ABO blood types are A, B, AB, and O: if an individual has the “A” antigen on the red cells, the patient has type A blood; the “B” antigen, type B blood; both the “A” and “B” antigen, type AB blood; neither antigen, type O blood. Naturally occurring antibodies to the opposite type of blood are present in an individual at birth. For example, people who have the “A” antigen on their red blood cells have the “B” antibody in their serum, and those with the “B” antigen have the “A” antibody. Table 30-3 further explains this process.
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FI E L D S M A R T S Type O blood is known as the “universal donor” because the surface of the red cells does not have either of the A or B antigens that can react with the naturally occurring antibodies. Therefore, type O can be given to individuals with any type of blood. Type AB blood is known as the “universal recipient” because individuals with this type blood have no naturally occurring AB antibodies in their serum to react with the antigens on the transfused red cells. Therefore, individuals with type AB blood may receive any ABO blood type.
Rh Blood Typing Another major blood type that must be considered in transfusions, organ transplants, and in pregnancy is the Rh blood group, named for the Rhesus monkey. A person either has the Rh antigen (Rh positive, Rh+) or does not (Rh negative, Rh–). Approximately 85% of North Americans are Rh positive. This typing is usually performed along with ABO typing using the test serum Anti-D. While the ABO antibodies are naturally occurring, the Rh antibodies are not. Antibody production against the Rh factor must be stimulated or caused. When an Rh negative person receives a transfusion of Rh positive blood, there will usually be no reaction with the first transfusion; however, antibodies to the Rh factor will begin to develop in about two weeks post-transfusion. A second transfusion of Rh positive blood can result in a life-threatening reaction. During pregnancy, the Rh factor must be considered if the mother is Rh negative and the father is Rh positive. If the baby inherits the Rh factor from the father and has Rh positive blood, future pregnancies for the mother can be affected. The baby’s red cells enter the mother’s blood stream during delivery and
the mother’s body will recognize the cells as “foreign” and will begin to make antibodies against the Rh positive invader soon after delivery. A medication known as RhoGAM is administered by injection to the mother at around 28 weeks gestation and again within 72 hours following delivery of the baby. This prevents her from forming antibodies against the Rh factor and will prevent any incompatibility problems with subsequent pregnancies. If the antibodies are allowed to form, they will attack future babies’ blood cells and can cause a serious disease known as HDN, or hemolytic disease of the newborn.
DRUG TESTING On-the-job drug use is becoming a growing problem in the workplace, accounting for increased absenteeism and on-the-job accidents. Many places of employment are developing a no-tolerance policy, and now require drug testing as a prerequisite for employment and also require random drug testing throughout employment. Employers may conduct drug testing at the following intervals:
TABLE 30-3 Antigens and Antibodies of the ABO Blood Group ABO BLOOD TYPE
ANTIGEN PRESENT ON THE RBCS
ANTIBODY PRESENT IN THE SERUM
Type A
“A”
Anti-B
Type B
“B”
Anti-A
Type AB
Both “A” and “B”
No ABO antibodies
Type O
Neither antigen is present
Both Anti-A and Anti-B
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❖ During preemployment testing ❖ When an incident or irrational behavior occurs on the job ❖ During random screenings A blood sample is more precise when testing for the presence of drugs, but also quite costly and time consuming. Therefore, urine drug testing is usually performed. It is less costly, easier to perform, and noninvasive. Urine drug screenings test for the most commonly abused drugs such as: ❖ ❖ ❖ ❖ ❖ ❖ ❖
Marijuana Amphetamines PCP Cocaine Opiates Barbiturates Benzodiazepines
Initial testing is only a screening and a positive result must be confirmed with more precise tests. Because some individuals fear the discovery of illegal substances in their drug screen, they may attempt to tamper with their specimen. Some people have even attempted to have a drug-free person provide the sample to avoid detection. Therefore, strict security measures must be followed to ensure the integrity of the specimen.
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Alcohol and drug testing may also be performed immediately following a vehicular accident or during criminal investigations. This testing is normally performed in a hospital environment or special reference laboratory.
Chain of Custody Steps must be taken to ensure the validity of a specimen for alcohol and drug testing. This procedure is known as the “chain of custody.” A specific protocol must be followed during collection and handling of the specimen; if not, the chain is broken. Steps usually included in the chain of custody are: 1. Identify the patient and check a photo ID. 2. Thoroughly explain the collection process to the patient and have the patient sign a consent form (Figure 30-13). This consent is sometimes part of the chain of custody form. The consent form explains the purpose of the test and gives the health care professional permission to collect and handle the specimen. Consent also gives permission to send the specimen for testing and to give the results to the requesting agency. 3. Explain to the patient that prescription and OTC drugs will be detected in the sample and instruct the patient to list all medications or substances taken within the last 30 days.
FIGURE 30-13 An I,
give my permission for ABC Health Center to collect a urine specimen for a
drug screening test, required by
as part of my preemployment physical.
List all medications you are presently taking:
My signature indicates that I understand that my employment is contingent on a negative drug screening.
Date: Witness:
Signature:
example of a consent form for drug screening
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4. Instruct the patient to remove all outer clothing and empty pockets. Females must leave purses outside the collection area. 5. Ask the patient to wash and dry the hands prior to collecting the specimen. No water may be running during specimen collection. 6. Explain the collection process to the patient and supply the patient with a specimen container. Sometimes, the health care professional may need to witness the collection procedure (occurs most often in cases where a crime has been committed). 7. After collection, check the specimen for any signs of alteration such as unusual color or odor. 8. Measure the temperature of the urine within four minutes of collection. Variations in tem-
9.
10. 11. 12. 13. 14.
perature could indicate tampering with the specimen. Transfer the specimen to a transport container while the patient witnesses the transfer. Place an identification label on the container, and instruct the patient to initial the label. Check the chain of custody form to ensure all information is complete. Note the date and time of collection and sign and print your full name. Give the patient a copy of the chain of custody form (Figure 30-14). Seal the specimen in a leak-proof bag. Give the specimen to the lab courier.
FIGURE 30-14 A chain of custody form that must be completed and must accompany the specimen to the laboratory. The patient must receive a copy of the form.
CHAIN OF CUSTODY FORM
CLINICAL LABORATORY
SPECIMEN I.D. NO:
STEP—1 TO BE COLLECTED BY COLLECTOR OR EMPLOYER REPRESENTATIVE Employer Name:
Medical Review Officer Name and Address:
Address:
OR
I.D. No:
Donor Social Security No. or Employee I.D. No.: Donor I.D. Verified:
Employer Representative
Photo I.D.
Signature
Reason for test: (check one)
Preemployment
Random
Periodic Return to duty
Reasonable suspicion/cause Other(specify)
Postaccident
Test(s) to be performed:
Total tests ordered Urine
Type of specimen obtained:
Blood
Semen
Other (specify)
Submit only one specimen with each requisition.
STEP 2—TO BE COMPLETED BY COLLECTOR For urine specimens, read temperature within 4 minutes of collection. Check here if specimen temperature is within range: Yes, 90o−100o F/32o− 38o C Or record actual temperature here:
STEP 3—TO BE COMPLETED BY COLLECTOR Collection site:
Address:
City: Collection date:
State: Time:
Zip: a.m.
Phone: p.m.
I certify that the specimen identified on this form is the specimen presented to me by the donor identified in step 1 above, and that it was collected, labeled, and sealed in the donor's presence. Collector's name: Signature of collector:
STEP 4—TO BE INITIATED BY DONOR AND COMPLETED AS NECESSARY THEREAFTER Purpose of change
Released by Signature
Received by Signature
A. Provide specimen for testing B. Shipment to laboratory C. Comments:
STEP 5—TO BE COMPLETED BY THE LABORATORY Specimen package seal(s) intact when received in lab? Laboratory receiver's initials:
Yes
No. If no, explain.
Date
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H I PA A PAT R O L You must never tell another individual that a certain patient was in for testing at the facility in which you work. It may be very tempting to tell friends or members of your family that a common acquaintance failed a drug test. If this information is divulged, it may cause the patient
emotional and mental anguish and may provoke the patient to file a lawsuit against the facility in which you work. By telling others about your findings, you could lose your job, face a lawsuit yourself, and permanently lose your certification or registration as a medical assistant.
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TABLE 30-4 Quick Reference for Common Chemistry Tests TEST NAME
TEST ABBREVIATION
REFERENCE RANGE*
CLINICAL SIGNIFICANCE
Albumin
ALB
3.0–5.0 g/dL
Liver, kidney, and nutritional status
Alkaline phosphatase
ALP
30–130 mU/L
Hepatobiliary and bone disease
Amylase
AMS
25–125 IU/L
Pancreatic disease
Bilirubin Total Direct Indirect
T Bil, Tbili, Bili DBil, Dbili IBil, Ibili
0.2–1.0 mg/dL 0.0–0.2 mg/dL 0.3–1.1 mg/dL
Liver disease and hemolytic anemia
Blood urea nitrogen
BUN
8–25 mg/dL
Kidney function
Calcium
Ca
8.5–10.5 mg/dL
Parathyroid disorders
Cancer detection Carcinoembryonic antigen
CEA
Various types of cancer
Prostate-specific antigen
PSA
>5.0 ng/mL smoker >3.0 ng/mL nonsmoker 0–4 ng/mL
Creatine kinase
CK, CPK
Males: 12–70 µ/mL Females: 10–55µ/mL
Cardiac muscle damage
Creatinine
Creat
0.4–1.5 mg/dL
Renal function
C-Reactive protein
CRP
>6 mg/L
Bacterial infections, acute rheumatic fever, SLE (systemic lupus erythematosus), active rheumatoid arthritis
Electrolytes Sodium
Analytes Na
136–145 mEq/L
Potassium
K
3.5–5.0 mEq/L
Chloride
Cl
96–110 mEq/L
Diabetes insipidus, diarrhea, and dehydration Diuretic therapy, starvation, and liver disease Renal disease, CHF, anemia, dehydration
Gamma-glutamyl transpeptidase
GGT, GGTP
Males: 9-70 U/L Females: 5-45 U/L
Prostate cancer and prostate disorders
Pancreatitis and liver disorders continues
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TABLE 30-4 Quick Reference for Common Chemistry Tests (continued) TEST NAME
TEST ABBREVIATION
REFERENCE RANGE*
CLINICAL SIGNIFICANCE
Globulin
Glob
1.5–2.5 g/dL
Rhematoid arthritis, Hodgkin’s disease, and chronic infections
Glucose Fasting blood sugar Two-hour postprandial Glucose tolerance test
FBS 2 HPP GTT
All tests listed help to diagnose and follow the management of diabetes.
Hemoglobin A1c or glycosylated hemoglobin
HbA1c
70–110 mg/dL >140 mg/dL Fasting: 70–110 mg/dL 1/2 hr: 110–170 mg/dL 1 hr: 120–170 mg/dL 2 hr: 70–120 mg/dL 3 hr: 60–120 mg/dL 4.5–6.5
Lactate dehydrogenase
LDH, LD
100–225 U/L
MI, pulmonary infarction, liver disease, muscular dystrophy, and pernicious anemia
Lipase
None
0–1.5 U/ml
Acute pancreatitis, pancreatic cancer
Lipids Total cholesterol High-density lipoprotein Low-density lipoprotein Triglycerides
Chol HDL (good) LDL (bad) Trig
>200 mg/dL Males: 37–70 mg/dL Females: 40–85 mg/dL >130 mg/dL 20-180 mg/dL
Coronary artery disease and also assesses the risk of developing coronary heart disease (CHD)
Magnesium
Mg, Mag
1.2–2.4 mEq/L
Malnutrition, diarrhea, pancreatitis
Phosphorous
P
2.5–4.5 mg/dL
Parathyroid, renal, and diabetic disorders
Total protein
TP, TPRO
6.0–8.0 g/dL
Dehydration, multiple myeloma, nephrotic syndrome, severe burns
Prothrombin time
PT
10–13.4 seconds
Abnormal bleeding disorders and anticoagulation therapy
Serum glutamicoxaloacetic transaminase
SGOT, AST
5–40 U/L
MI, muscular dystrophy, infectious mononucleosis, and liver disease
Serum glutamicpyruvic transaminase
SGPT, ALT
7–56 U/L
Liver disorders, MI, and muscular dystrophy
TSH
0.3–4.5 mU/mL
Thyroid disorders
T3 T4
4.5–13.0 mU/mL 280–480 pg/dL
UA
Males: 3.5–7.2 mg/dL Females: 2.6–6.0 mg/dL
Thyroid tests Thyroid stimulating hormone Triiodothyronine Thyroxine Uric acid
Indicates blood glucose control over the previous three month period
Renal failure, gout, leukemia, and lymphomas
*Unless otherwise noted, all reference ranges are for adults. Please note: Reference values were compiled from several different sources and can vary according to test methodology.
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PROCEDURE 30-1 Measure Blood Glucose Using a Handheld Monitor Objective: To determine blood glucose levels at intervals requested by the provider to aid in the management of diabetes.
Equipment/Supplies: ❖ ❖ ❖ ❖ ❖ ❖ ❖
Gloves PPE Glucose monitor Glucose test strips Sterile lancet and lancing device Control solution Antiseptic wipe
PROCEDURAL STEPS
❖ Biohazard waste container ❖ Sharps container ❖ Patient’s chart RATIONALE
1. Check the provider’s order, and assemble the equipment and supplies. Check the expiration date on the reagent strip and control containers.
Expired strips can cause inaccurate test results.
2. Wash your hands and apply PPE.
PPE should always be worn whenever exposure to blood is possible for protection against splatters.
3. Calibrate the instrument and run a control sample according to the manufacturer’s instructions.
Calibrating the instrument and running controls help to ensure that both the unit and strips are working properly.
4. Identify the patient using two identifiers, identify yourself, and explain the procedure. Verify if the patient is fasting or not.
Determining if the patient is fasting may assist with interpreting results.
5. Ask the patient to wash and dry the hands.
Washing the hands with warm water reduces microorganisms and stimulates blood flow to the area.
6. Cleanse the puncture site with an antiseptic wipe, allowing the site to dry before puncturing.
Puncturing before allowing the antiseptic to dry may cause stinging and the wet alcohol could interfere with the results.
7. Turn the unit on and check to make certain that the code number on the monitor matches the code number on the reagent strip container (Figure 30-15).
If the codes do not match, accurate results cannot be guaranteed.
8. Wait until the blood drop icon appears on the monitor screen (this may vary in some units) and then puncture the site.
Placing the blood on the strip before the unit is ready may cause a malfunction to occur.
9. Puncture the site with a safety device and dispose of it in a sharps container. Wipe away the first drop of blood (refer to Procedure 26-4).
Using the first drop of blood may produce an inaccurate reading because of the increase in tissues fluid.
FIGURE 30-15 The medical assistant inserts a test strip into the monitor and verifies that the code number on the bottle matches the code number on the meter.
continues
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continued
PROCEDURAL STEPS
RATIONALE
10. Touch one edge of the test strip to the drop of blood and allow the strip to absorb the blood (Figure 30-16).
Advancing the strip into the drop of blood rather than the patient's skin will produce a more accurate result.
11. Instruct the patient to apply pressure to the puncture site with a cotton ball.
Applying pressure helps to stop the bleeding and reduces bruising.
12. Wait for the reading to appear on the screen (Figure 30-17).
If the test did not read properly, an error code will appear instead of the results.
13. Remove the reagent strip from the monitor and dispose of properly.
The test strip contains blood and should be placed in biohazardous waste.
14. Remove gloves and wash your hands.
Cleansing the hands after removing gloves helps to reduce cross-contamination.
15. Document the test results in the patient’s chart and the lab log.
FIGURE 30-16 The test strip is gently touched to the drop of blood.
FIGURE 30-17 The result is automatically displayed.
Documenting in the patient’s chart verifies that the procedure was performed.
DOCUMENTATION EXAMPLE:
06-10-XX 9:00 a.m.
FBS per Dr. Jones, Result: 78 mg/dL, verified pt. fasted for the appropriate amount of time. Manufacturer: Smith Diagnostics, Lot # 65487, Exp 01/01/XX. Melanie Maren, CMA (AAMA)
PROCEDURE 30-2 Perform a Urine Pregnancy Test Objective: To determine the presence of hCG in the urine, indicating pregnancy.
Equipment/Supplies: ❖ ❖ ❖ ❖ ❖ ❖ ❖
Gloves PPE Urine specimen QuickVue One-Step hCG urine test kit Timer Biohazard waste container Patient’s chart
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PROCEDURAL STEPS
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RATIONALE
1. Check the order and assemble the test kit, the patient urine sample, and all necessary supplies. Read the test kit directions.
All test kits are different so reading the directions will ensure proper performance of the test.
2. Wash your hands and apply gloves and other required PPE.
PPE helps to prevent you from becoming contaminated.
3. Perform a control.
A control confirms the kit is working properly.
4. Open the test unit, and using the dropper provided in the test kit, add three drops of urine to the test well (Figure 30-18) or follow the directions on the test kit.
The dropper from the kit must be used, because it is designed to deliver the precise amount of urine required for the test.
5. Allow the test to develop for precisely three minutes. Set a timer for accurate timing of the test.
Accurate timing is crucial for accurate results.
6. Read the test window and determine if the results are positive or negative (Figure 30-19). Check for a line beside the control display.
If there is no line by the control, the unit may not be functioning properly.
7. Properly dispose of used equipment, test unit, and specimen.
Proper disposal of used equipment and specimens helps to control the spread of disease.
8. Remove gloves, wash your hands, and record results in the patient’s chart and the appropriate logs.
Removing gloves and cleansing the hands before documenting in the patient’s chart helps to prevent contamination. Documentation verifies the procedure was performed.
DOCUMENTATION EXAMPLE:
06-01-XX 11:30 a.m.
Performed QuickVue hCG test per Dr. Stevens, Result + Lot # 123456. Exp. 01/01/XX Melanie Maren, CMA (AAMA)
3 drops
Round sample well Result window
FIGURE 30-18 Add three drops of urine to the test well. (Courtesy of the Quidel Corporation.)
POSITIVE (+)
NEGATIVE ( )
(a)
(b)
FIGURE 30-19 (a) A positive result; (b) a negative result (note the control line) (Courtesy of the Quidel Corporation.)
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PROCEDURE 30-3 Perform a CLIA Waived Mono Test Objective: To perform a CLIA waived test to confirm or rule out a diagnosis of infectious mononucleosis.
Equipment/Supplies: ❖ ❖ ❖ ❖ ❖ ❖ ❖
Patient specimen Control (if necessary) Gloves PPE Mono test kit Biohazard waste container Patient’s chart
PROCEDURAL STEPS
RATIONALE
1. Check the order and assemble the test kit, the patient sample, and all necessary supplies.
Having the patient sample and all supplies readily accessible saves time.
2. Wash your hands and apply gloves and other required PPE.
PPE must be worn when working with any body fluids to prevent possible contamination.
3. Perform the test following the manufacturer’s directions. Be sure to run a control along with the test.
Each test kit may differ slightly, so the manufacturer’s directions must be read and followed exactly each time the test is performed. Running a control helps to ensure that the test kit is working properly.
4. Properly dispose of all equipment.
Proper disposal will help to eliminate cross-contamination.
5. Remove gloves and wash your hands.
Handwashing helps prevent cross-contamination.
6. Record the results in the laboratory log and also document the results in the patient’s chart.
The results should be recorded in the log according to the facility’s policies and also in the patient’s chart so there will be a permanent record of the results.
DOCUMENTATION EXAMPLE:
10-10-XX 10:00 a.m.
Performed rapid mono test per Dr. Leonard, Result +, Manufacturer: Smith Diagnostics, Lot # 20937548900. Lillian Karnes, CMA (AAMA)
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Chapter Summary A variety of chemistry, serology, and miscellaneous tests have been covered within this chapter. While the medical assistant may not perform a large percentage of the tests presented in the chapter, the medical assistant should have a basic knowledge of the most common tests, their clinical significance, and their normal values. Medical assistants should be able to perform all CLIA waived tests, along with proper quality control and procedure documentation. They must also understand the chain of custody for drug testing and be able to properly explain specimen collection for drug testing to the patient.
FIELD APPLICATION CHALLENGE You are instructed by the physician to obtain an FBS from a patient. The physician is concerned about adjusting the patient’s medication and does not want to add a new medication if it is not necessary. You assemble all equipment and perform the blood glucose test. A control was not performed. The result is 190 mg/dL. The physician feels compelled to add a new medication based on the test results.
1. Why is it so important to run a control before testing the patient’s sample? 2. If the test was not accurate, is the medication change that the physician is proposing going to cause a problem for the patient?
Chapter Assessment 1. Which of the following tests screens for syphilis? a. VDRL b. HIV c. SYP d. STD
5. A pregnancy test determines the presence of: a. hCG. b. T3. c. TSH. d. FSH.
2. What is a blood glucose level of 50 mg/dL indicative of? a. Hyperglycemia b. Glycemia c. Glycogenemia d. Hypoglycemia
6. A high level of LDL cholesterol can put a patient at risk for developing: a. cancer. b. colitis. c. CAD. d. TIA.
3. The most likely way a patient contracts infectious mononucleosis is: a. sexual contact. b. contaminated food or water. c. vector. d. through contact with infected saliva.
7. Which of the following is a tumor marker for colorectal cancer? a. PSA b. ALP c. SGPT d. CEA
4. A patient’s blood tests negative with both Anti-A and Anti-B test serum, indicating which blood type? a. AB b. O c. A d. B
8. Which of the following tests is used as an indicator of blood glucose control? a. HbA1c b. FBS c. GTT d. 2 HPP
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9. Patients on anticoagulant therapy must regularly have which of the following tests? a. Bleeding time b. PT/INR c. APT d. Thrombin level
Web Activities 1. Visit the American Diabetes Association’s Web site at http://www.diabetes.org for the most current recommendations for FBS levels. 2. Surf the CLIA ’88 Web site for the latest information on new devices that medical assistants can use in the POL to conduct laboratory testing.
CONNECTION Using your StudyWARE CD-ROM: ❖ Complete the Crossword Puzzle and Concentration activities for this chapter. ❖ Complete the Quiz for this chapter in Test Mode.
THE DVD LINK On your StudyWARE CD-ROM, go to the DVD Challenge for this chapter. View the DVD clip and respond to the following questions: 1. What was the purpose of running the control prior to performing the test? 2. The area in which the medical assistant performed the stick was just a bit high. What part of the finger might have been a better choice for the puncture? 3. In the field, you will notice that each health care worker has a unique method for cleaning the puncture site. The medical assistant in this clip went back and forth over the site several times with an alcohol pad. What method does your instructor want you to use for cleaning the site? 4. What was the result for the glucose test on this patient? Was it normal?
C H A P T E R
Diagnostic Imaging
Essential Terms
Chapter Outline Radiology Overview Legal Considerations for Taking X-Rays X-Ray Equipment Digital Radiography The Medical Assistant’s Role in Radiographic Procedures Positioning the Patient Common Types of X-Rays Performed in the Office Processing and Displaying X-Ray Films Storing and Disposing of X-Ray Films Safety Precautions Personnel Safety Precautions Patient Safety Precautions
31
Scheduling Radiological Procedures Outside the Office Patient Preparation Instructions Explaining the Procedure Radiological Procedures Commonly Performed Outside the Office Other Diagnostic Imaging Procedures Computed Tomography/CT Scan Magnetic Resonance Imaging (MRI) Ultrasound/Sonography Nuclear Medicine Radiation Therapy
angiography bucky cholangiography collimator computed tomography (CT) contrast medium fluoroscopy grid intravenous pyelogram (IVP) magnetic resonance imaging (MRI) nuclear medicine rad radiograph radiologist radiolucent radionuclide radiopaque ultrasound x-ray
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Developmental Objectives After completing this chapter, you should be able to: 1. Correctly spell and define essential terms. 2. Describe four patient positions used for x-rays. 3. Discuss the role of the medical assistant with regards to radiographic procedures. 4. List the risks associated with x-rays. 5. Explain safety precautions used by health care personnel and patients during x-rays. 6. Discuss the preparation for a skeletal x-ray. 7. Explain the patient preparation for an IVP. 8. Compare and contrast the different types of radiographic procedures used to diagnose patients. 9. List the uses and side effects of radiation therapy. 10. Explain the advantages of ultrasound over x-ray during pregnancy.
Introduction X-rays, along with other radiological and diagnostic imaging procedures, are often included in the “Plans” section of the progress note. One purpose for requesting an x-ray is to confirm a diagnosis or to rule out other possible causes related to the patient’s symptoms. Radiological procedures may also be used for treatment purposes in particular types of malignancies. A radiologist is a physician who has received additional training in the use and interpretation of radiological examinations and is usually the medical specialist who oversees a hospital radiology department or an outside x-ray facility. Some states allow medical assistants to perform general x-rays once they complete additional training and acquire a special x-ray license or certificate. Even if not permitted to perform x-rays, medical assistants should have a basic understanding of the different types of radiographic procedures that are commonly ordered and be familiar with preparation instructions for each one.
RADIOLOGY OVERVIEW German physicist Wilhelm Roentgen (who received a Nobel prize in 1901) is credited with discovering the x-ray. Experimenting with a glass tube, a cathode ray tube, and electric currents, he was able to witness the production of a fluorescent light that produced pictures on photographic plates. He named his discovery “Xradiation,” which has since been shortened to x-ray. Further exploration found that the light could penetrate other materials, including human tissue, which permitted visualization of structures within the body without surgical intervention. The discovery of the x-ray proved to be a major step in the field of modern medicine. In current medicine, x-rays or radiographs are beams of radiation used to visualize internal components of the body. Pictures of various body parts are produced in varying shades of black and white, dependent on the mass of the tissue. Bones, being very dense, appear whiter on an x-ray. Muscles and organs take on gray hues, as they are less dense and can absorb more of the x-ray. If the beam
DIAGNOSTIC IMAGING
passes through air, as occurs when passing through tissue within the lungs and parts of the colon, the rays appear as a darker shade of gray or black.
LEGAL CONSIDERATIONS FOR TAKING X-RAYS In many states, only licensed radiographic technicians may perform x-rays; however, some states allow individuals such as medical assistants the opportunity to obtain a limited license to perform very basic flat films, such as x-rays of the limbs and chest. The individual will go through a short training class and sit for a special licensing exam that will allow the individual to take limited radiographs with particular types of equipment. The introduction of digital imaging is limiting opportunities for medical assistants to perform x-rays in some states. This may change in the future. Medical assistants interested in taking x-rays should check the x-ray licensing requirements in the states in which they work to determine if there is an opportunity to obtain a limited radiography certificate or license.
X-RAY EQUIPMENT Medical assistants who are licensed to perform x-rays and work in offices that have x-ray equipment (Figure 31-1) should become familiar with the equipment and procedures that are used in each particular office. X-ray equipment is comprised of the following components:
FIGURE 31-1 An illustration of x-ray equipment used to take film x-rays
X-ray tube
X-ray lm
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❖ X-ray tube: The x-ray tube is the part of the equipment that emits radiation. The tube itself is encased in a protective covering in which different components are attached. These specialized components assist with the movement of the tube and the adjustment of the size and shape of the x-ray beam. ❖ X-ray table: The table is the part of the equipment on which the patient lies. Most tables are adjustable for different positioning. The table may be raised, lowered, or tilted so that the patient is in a standing position. ❖ Collimator: This device, attached to the x-ray tube, controls the size and shape of the x-ray beam. ❖ Cassette: The cassette is a frame that holds the film and two intensifying screens (Figure 31-2). ❖ Intensifying screens: One screen is positioned above the film and one below. The screens are coated with particles that emit light when exposed to the x-ray beam. The screens allow lower doses of radiation to be used when performing an x-ray on a patient. ❖ Grid: This component is placed below the x-ray table between the table and the film to prevent the x-ray beam from scattering, which helps to produce a clearer image. ❖ Bucky: The bucky holds a cassette tray in which the film is placed. During the x-ray, the bucky moves the grid out of the way to prevent it from being visible on the film. ❖ Control panel: The control panel is the part of the unit that controls the energy and concentration of the radiation being generated. The radiographer will determine the settings needed and stand either behind a lead shield or in an enclosed area
FIGURE 31-2 The cassette that holds the x-ray film
X-ray beams
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FIGURE 31-4 The provider and other members of the health care team can view the very clear digital x-ray image by looking at the computer screen.
FIGURE 31-3 The control panel of the x-ray unit is located in an enclosed area with lead walls to keep the medical assistant safe from scattering radiation.
with lead-lined walls while taking the x-ray (Figure 31-3). ❖ X-ray processor: This unit develops the films.
Digital Radiography As technology becomes more sophisticated, traditional film imaging is on the decline. Filmless imaging provides better quality images and saves an enormous amount of space. There is no need for films and pro-
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E M R A P P L I C AT I O N EMR makes viewing and storing digital x-rays very easy. When the x-ray is taken, the image is sent to the patient’s EMR, where it is stored for future use. There is no longer a need for space to store the x-rays. X-rays can be sent to other specialists at the click of a button. If the specialist doesn’t have EMR, the medical assistant will make a CD of the image and send it with the patient.
cessors, and these images can be sent anywhere in the world in a matter of seconds, as long as the receiver has the technology to receive and view the images (Figure 31-4). Digital equipment is quite expensive for smaller clinics and provider’s offices, but as prices decline over the next several years, more offices will move toward digital radiography.
THE MEDICAL ASSISTANT’S ROLE IN RADIOGRAPHIC PROCEDURES The medical assistant’s role in taking x-rays will vary from office to office and from state to state. The following list depicts the usual duties of the medical assistant in performing x-rays: ❖ Explaining the procedure ❖ When working with a female, making certain that there is no risk of pregnancy before taking the x-ray ❖ Providing disrobing instructions for the patient and instructing the patient on what jewelry needs to be removed (any metals such as necklaces, earrings, rings, etc. should be removed from the viewing area, or it will show up on the film) ❖ Positioning the film in the cassette and placing a label on the cassette that displays the patient’s name, the type and exact location of the x-ray, and the date the x-ray is performed
DIAGNOSTIC IMAGING
❖ Using a caliper (Figure 31-5) to perform body measurements on the surfaces that will be exposed to x-rays ❖ Adjusting the settings on the x-ray machine to match the patient’s measurements ❖ Placing lead aprons or shields on the patient to limit the amount of x-ray exposure, especially to the reproductive organ area ❖ Positioning the patient so that the tube lines up with the cassette ❖ Adjusting the collimator so that the beam only includes the area to be viewed ❖ Performing the x-ray ❖ Developing the films ❖ Displaying the x-ray ❖ Storing the x-ray ❖ Documenting the x-ray
Positioning the Patient Proper positioning of the patient is essential in order to x-ray the right part of the body and to produce a clear image. The provider will write an order for the x-ray and indicate which position should be used for the procedure. The medical assistant should be familiar with the different patient positions in order to understand and carry out the provider’s orders. Table 31-1 lists common radiological positions and gives a brief description of each.
COMMON TYPES OF X-RAYS PERFORMED IN THE OFFICE A number of simple x-rays can be taken in the medical office. Table 31-2 lists some of the more common ones
FIGURE 31-5 A caliper that is used to measure parts of the body before taking an x-ray
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C R I T I C A L T H I N K I NG CHALLENGE After taking an x-ray and developing the film, you notice that the patient’s necklace is visible on the x-ray. 1. What should you do?
performed in-house, along with a description of the x-ray and the positions used for each one.
PROCESSING AND DISPLAYING X-RAY FILMS Once the x-rays have been taken, the film must be developed to produce the image. The x-rays are developed in a darkroom, similar to those used to develop film from a camera. The medical assistant must avoid turning on overhead lighting or accidentally opening the door to the darkroom when working with x-ray film or it will become damaged. X-ray film is very expensive, and because several films are contained in one case, the whole case may be ruined if light enters the room. Many facilities have automated film-developing units. The film is fed into the processor, which moves it through the proper chemicals, dries it, and sends it out of the unit. The medical assistant should view the film and make certain that the image is clear, includes all regions requested, and that the identification information is correct before taking it out to the provider. Once the films are processed, the medical assistant will place the films in the view box.
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FI E L D S M A R T S With digital radiography equipment, film is no longer necessary, so there is no need for darkrooms or processors. There is also no need for view boxes because the image is viewed from the computer screen.
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TABLE 31-1 Common Patient Positions for X-Rays POSITION
DESCRIPTION
Anterioposterior (AP)
The x-ray beam is directed from the anterior surface to the posterior surface. If the patient is in a supine position, the x-ray tube will be directed toward the front of the patient’s body and the patient’s back will be positioned against the film. The x-ray beam travels from front to back.
Posterioanterior (PA)
The x-ray beam is directed from the posterior surface to the anterior surface. If the patient is standing, the x-ray tube will be directed toward the patient’s back and the front of the patient’s body will be against the film. The x-ray beam travels from back to front. In this image the beam is traveling from the back of the patient’s hand to the front.
Lateral
This position can either be a right lateral (RL) or a left lateral (LL). In a lateral position the direction (left or right) refers to the position of the patient in relation to the film, not the tube. The patient’s right side is against the film in the RL position and the patient’s left side is against the film in the LL position.
Oblique
The patient’s body area is placed against the film at an angle. This position is used to capture images that may be hidden in the previous views.
Erect
The patient is standing completely erect with either the front surface of the body toward the film or the back surface of the body toward the film.
Supine
The patient lies flat on the back on the x-ray table.
DIAGNOSTIC IMAGING
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TABLE 31-2 Common X-Rays Performed in the Medical Office TYPE OF X-RAY
ROUTINE VIEWS
DESCRIPTION OF THE PROCEDURE
Abdomen
AP (supine and erect view)
A flat film to view structures and organs within the abdomen, including the stomach, small and large intestines, spleen, liver, diaphragm, and the abdominal cavity
Bone/Skeletal
AP Lateral Oblique
X-rays to view abnormalities or injuries associated with the bones (Figure 31-6) Spinal views are also part of this series and include: • Cervical views (neck region) • Thoracic views (middle back region) • Lumbar sacral (lower back region)
Chest
PA Lateral (usually erect film)
Flat films of the chest to view the lungs and heart for any abnormalities or lung disease. This x-ray can also detect an enlarged heart.
KUB
Supine
Flat plate to view the kidneys, uterus, and bladder to detect kidney stones and any abnormal masses present
Sinus
PA The patient’s face is against the film.
X-ray of paranasal sinuses to detect signs of infection, inflammation, and other abnormalities
FIGURE 31-6 An x-ray image of a severe fracture of the femur
STORING AND DISPOSING OF X-RAY FILMS Proper storage and handling of x-ray film is crucial. Film can be damaged by light, moisture, heat, or exposure to chemicals. Unexposed films should be stored in a special metal drawer or cabinet located within a darkroom. Exposed films, such as patient x-rays, should be stored in envelopes made for that purpose (Figure 31-7) and should be filed in an appropriate area. The length of time that patient x-rays have to be kept will vary according to individual state statutes and provider preference, but will usually range from five to seven years. Once this time has passed, the x-ray can be disposed of using proper disposal techniques. X-ray recycling companies will come to offices and remove outdated films, shred the films, and recycle the films for precious metals. The film is weighed, and the office may receive a fee for the silver extracted from the film.
FIGURE 31-7 Special envelopes designed for storage of x-ray films
SAFETY PRECAUTIONS Individuals can be exposed to radiation when in close proximity to the area where x-rays are performed.
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H I PA A PAT R O L Because x-rays are considered part of the patient’s medical record, they must be protected once they leave the office. Most disposal and recycling companies are HIPAA compliant and will provide a tracking certificate that illustrates what happens to those x-rays from the time they leave the provider’s office until they are destroyed. This certificate should be stored in a special log book for future review.
Excessive exposure can lead to tissue damage, a lowered red blood and white blood cell count, bone marrow damage, damage to the ovaries and testes, fetal damage, cancer, and burns. Steps must be taken to protect both the health care worker and the patient from overexposure to radiation. The amount of radiation emission is measured in several different ways. The rad (radiation absorbed dose) is the unit used to measure the amount of what is known as “ionizing” radiation that is absorbed during an x-ray procedure. This same type of radiation can also be found in the environment from facilities such as medical testing and treatment sites and nuclear weapons sites. Ionizing radiation can also come from outer space and is found in individuals who have been exposed to radon. The amount of radiation that is emitted during an x-ray is far less than that which occurs naturally from the environment.
Personnel Safety Precautions During an x-ray, the radiation that strikes the patient is known as “primary” radiation. Some of this primary radiation then bounces off the patient and becomes what is known as “secondary” radiation. It is the secondary radiation that health care workers must protect themselves from. The level of secondary radiation is the highest in areas closest to the patient. Barriers must be used to prevent absorption of the scattered beams to other individuals outside of the room and to individuals taking the x-rays. An effective barrier to the radiation produced by x-rays is lead. Lead aprons (Figure 31-8) and lead gloves should be worn by the medical assistant if the medical assistant must remain in the room when an x-ray is taken. (This is sometimes necessary when a
FIGURE 31-8 An example of a lead apron
child is having an x-ray, or to hold a particular body part in place during an x-ray.) Since the radiographer does not usually remain in the room, the radiographer may stand behind a lead shield, or in an enclosed area in which the walls are lined with lead. The radiographer can then operate the control panel without being exposed to radiation. The walls of the room where the x-ray equipment is housed are lined with at least one inch of metal to prevent the scattered radiation from escaping outside of the room. Personnel who take x-rays or work in close proximity to radiologic equipment should wear a film badge (Figure 31-9), known as a dosimeter, that contains a small piece of film that will record the level of radiation exposure. The badge
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FI E L D S M A R T S All radioactive materials used in x-ray procedures must be stored in containers made of lead and should never be handled with bare hands. Special forceps must be used when handling any of these radioactive materials.
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FI E L D S M A R T S When the patient is not certain about pregnancy, a pregnancy test should be performed prior to taking the x-ray. The provider will then decide how to proceed.
x-rays or in the vicinity where x-rays are taken
SCHEDULING RADIOLOGICAL PROCEDURES OUTSIDE THE OFFICE
is checked at regular intervals to determine if radiation exposure has occurred and the level of radiation that was absorbed.
It is usually the medical assistant’s responsibility to schedule radiological procedures performed outside the office. The following information should be provided to the outside facility when scheduling an appointment:
FIGURE 31-9 A film badge worn by personnel working with
Patient Safety Precautions When taking x-rays, the general rule of thumb is to use the smallest amount of radiation possible to achieve the best results. This will reduce the exposure to the patient as well. Female patients who may be pregnant should not receive x-rays, unless it is an emergency situation. A grid, which was discussed earlier in the chapter, is used to absorb the secondary radiation from the x-ray. A bucky grid consists of alternating strips of lead—a radiopaque and a radiolucent (penetrable by x-rays) material. Both of these materials absorb some of the secondary radiation and allow the x-rays to penetrate the tissue at the same time. Not all of the secondary radiation can be absorbed by the grid, so alternate safety measures must be taken. Patients should be shielded with a lead apron that covers the thyroid gland, breasts, and gonad regions whenever possible.
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P ATIEN T TU T OR If a female patient is pregnant and an x-ray must be performed, the patient must be informed about the risks to the fetus before making the decision to have the x-ray. Many facilities will not take an x-ray if the patient is pregnant. They will look for alternative measures such as ultrasound.
❖ The patient’s full name and date of birth ❖ Insurance information, including precertification information, if needed ❖ Type of radiological study ❖ Diagnosis ❖ Provider information
Patient Preparation Instructions As mentioned earlier, it may be the medical assistant’s responsibility to schedule and educate patients for outside x-ray examinations. Information provided to the patient should include the following: ❖ Date and time of procedure ❖ Facility where procedure is to be performed ❖ Paperwork to take to the facility
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FI E L D S M A R T S Several radiological studies may be ordered for the same day. Always check with the facility to be sure that all studies can be performed during the same setting. Some studies may require certain substances to be introduced into the patient’s body that could interfere with subsequent studies, thus requiring the procedures to be scheduled on separate days.
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F IELD SM A RTS When scheduling radiological procedures to be performed outside the office, such as at a hospital radiology department or an independent radiology facility, be sure that the facility is one that accepts the patient’s insurance. Many insurance companies require patients to have studies performed at an “in-network” facility.
❖ Special preparation procedures ❖ Follow-up procedures The medical assistant should review the instructions verbally with the patient, but should provide the patient with written instructions as well. It is important to convey to the patient the importance of following the exact preparation listed on the instructions. Not following the preparation procedures correctly could
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CR ITI C A L TH I N K I N G C H AL LEN G E A patient who is scheduled for a lower GI series telephones the office the day of the procedure to say that he is unable to complete all of the preparation for the study. 1. How should you handle this scenario? 2. Should the patient report to the facility anyway?
In-network means that a particular facility contracts with specific insurance companies to provide services to their subscribers. If a patient has a radiological study performed at a facility that is not in-network, the patient’s benefits could be greatly reduced or the patient may have to pay for the study out-of-pocket.
result in a delay or cancellation of the procedure. Refer to Table 31-3 for patient preparation instructions for the most common radiological procedures.
Explaining the Procedure Many patients fear any type of medical exam, especially if it is a first-time procedure. Some diagnostic imaging equipment is large, noisy, and can be very intimidating to the patient; therefore, it is important to thoroughly explain all radiological procedures so the patient knows what to expect. Many x-rays are noninvasive and do not involve any pain or discomfort for the patient. Some, however, require the use of a contrast medium, which is a substance that is either ingested or injected to enhance internal structures for better visualization. A thorough explanation of the type of contrast medium to be used will help to alleviate patient anxiety.
Types of Contrast Media When photographed on x-ray film, the internal structures of the body appear as different shades of black and white, depending on their density or thickness. Bone tissue is very dense and will appear white on the film because the x-ray does not pass through it. In con-
C U LT U R A L AWA R E N E S S Cultural and language differences should be considered when scheduling a radiological exam. As discussed in Chapter 8, some cultures do not feel comfortable exposing personal body parts to people of the opposite gender. Many radiological procedures require sensitive body
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areas such as the breasts to be exposed. If at all possible, request that the facility use someone that is the same sex as the patient to perform the procedure. Explain the importance of having the x-ray to the patient and be sensitive to patient concerns.
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trast, the lung tissue is less dense than the bone tissue and the x-rays will pass through it, causing it to appear black on the x-ray film. If an internal organ or structure is difficult to view on an x-ray film, a contrast medium may be used. Contrast media are radiopaque, which means that the xray beams cannot penetrate the media. Therefore, if an internal structure, such as the intestines, is filled with a contrast medium, less rays will be absorbed, resulting in a lighter image that is easier to view. Contrast media are available in several forms: ❖ Liquid: Barium sulfate powder is mixed with water and the patient drinks the liquid to make the structures of the upper gastrointestinal tract more visible. Barium can also be administered as an enema for visualization of the lower GI tract. ❖ Iodine: Compounds containing iodine salts can be injected into the patient, usually intravenously, to visualize the kidneys, thyroid gland, heart, gallbladder, and blood vessels. It is important to determine if the patient has any allergies to seafood or iodine before scheduling the study.
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❖ Air or carbon dioxide: Air and other gases like carbon dioxide can be injected into the body to view the spinal cord and joints.
RADIOLOGICAL PROCEDURES COMMONLY PERFORMED OUTSIDE THE OFFICE Clinical examinations may indicate the need for further diagnostic procedures to help identify a particular disorder or illness. A diagnosis often depends on exploration of the internal tissues of the body. Rather than relying on surgical intervention for visualization, x-ray and other radiological procedures provide a less invasive method for observation. There are presently many specialized radiological and diagnostic imaging procedures available, with new studies being developed all the time. Table 31-3 lists some of the more common radiological procedures performed outside the office as well as their purpose, the area(s) assessed, patient preparation instructions, and the route that the contrast medium is administered.
TABLE 31-3 Common Radiological Procedures Performed Outside the Medical Office
PROCEDURE NAME Angiography
PURPOSE Visualization of the blood vessels to assess blood flow, clots, hemorrhaging, aneurysm
ORGANS/ BODY SYSTEMS ASSESSED
PATIENT PREPARATION INSTRUCTIONS
CONTRAST MEDIUM ROUTES
Heart Aorta Brain Lungs GI tract Kidneys
Nothing by mouth for six to eight hours prior to the exam
IV
An angiogram of the coronary arteries after the injection of a contrast medium
Arthrography
Visualization of the inside of a joint to assess the tendons, ligaments, and cartilage
Knee Hip Shoulder
None prior to the procedure Post-procedure: Some swelling and discomfort in the joint area may be present for one to two days following the study
Injection
continues
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TABLE 31-3 Common Radiological Procedures Performed Outside the Medical Office (continued) ORGANS/ BODY SYSTEMS ASSESSED
PATIENT PREPARATION INSTRUCTIONS
CONTRAST MEDIUM ROUTES
Visualization of the upper GI tract for assessment of ulcers, tumors, polyps, hiatal hernia, esophageal varices
Esophagus Stomach Small intestine
Day before procedure: Light evening meal and NPO (nothing by mouth) after midnight Day of procedure: NPO Post-procedure: Increased fluid intake and laxative, if prescribed
Oral contrast
Barium Enema/ Lower GI Series
Visualization of the lower GI tract for assessment of polyps, tumors, or lesions
Colon
Day before procedure: Administered Clear liquid diet, cleansing by enema of the colon with laxative agents, light evening meal, NPO after evening meal Day of procedure: NPO and a cleansing enema Post-procedure: Increased fluid intake and if no bowel movement within 24 hours after the procedure, report to the provider
Cholangiography
Visualization of the bile ducts for detection of possible stones or lesions
Bile ducts of liver
Possible cleansing enema prior to the procedure No meal before the exam
IV
Fluoroscopy
Visualization of moving body structures in real time, similar to a movie; often used during heart catheterizations
Heart Esophagus Stomach Blood vessels
NPO after midnight
Depending upon location of procedure: IV or oral contrast
Intravenous Pyelogram (IVP)
Visualization of the urinary tract for stones, obstructions, cysts, tumors
Kidneys Ureters Bladder
NPO prior to the procedure Laxatives the day prior to the procedure to cleanse the intestinal tract
IV
PROCEDURE NAME Barium Swallow/ Upper GI Series
PURPOSE
An x-ray of the stomach after the ingestion of barium
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P ATIEN T TU T OR Remind patients who are breastfeeding that there is a chance that the contrast media can be transferred to breast milk. Suggest that the patient use formula in place of breast milk for several days following a study in which a contrast medium is used.
OTHER DIAGNOSTIC IMAGING PROCEDURES
FIGURE 31-10 The patient lies on the table ready to enter the CT scanner.
Some diagnostic imaging procedures require the use of special equipment other than standard x-ray equipment. Many of these specialized procedures are performed in a hospital radiology department. However, some independent facilities have equipment that perform advanced imaging and more specialized procedures.
Computed Tomography (CT) Scan The computed tomography (CT) scan combines xray along with a computer analysis of body tissues and organs and can be performed with or without a contrast medium. CT scans can supply the provider with more detailed information than a traditional x-ray and can eliminate the need for more invasive procedures. It is a valuable tool in detecting tumors and lesions in multiple areas of the body. CT scans can also be used to pinpoint the area where radiation should be administered to treat a tumor or mass. During the scan, the patient lies on a table that moves into a doughnut-shaped scanner (Figure 31-10). The table advances in small increments while the scanner gathers separate images in the form of thin cross sections or slices of the tissue being studied (Figure 31-11). The scan does not usually require any special preparation and is both painless and noninvasive. If the scan requires the use of a contrast medium, the patient should be instructed not to eat or drink anything for four hours prior to the procedure.
Sagittal
Transverse
Magnetic Resonance Imaging (MRI) Magnetic resonance imaging (MRI) has become the diagnostic imaging procedure of choice for many providers and hospitals. MRI uses no radiation and produces a high quality, three-dimensional image that is
Coronal
FIGURE 31-11 Cross-sectional images produced by a CT scan
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During the MRI, the patient is placed in a cylindrical chamber and must remain inside for up to 60 minutes. Patients who suffer from claustrophobia may need to be sedated in order to undergo an MRI. Open MRIs are now available for patients who cannot tolerate a traditional MRI, but the image quality is not as clear and accurate as those produced by a closed MRI. The machine makes loud clanging noises during the procedure and some patients prefer to wear ear plugs or headphones to listen to music during the procedure. Refer to Figure 34-13 for pictures of both a closed and open MRI machine. While an MRI is a relatively easy procedure for the patient, there are some drawbacks, including:
FIGURE 31-12 An MRI image of the abdomen
much clearer than traditional x-rays (Figure 31-12). An MRI machine utilizes a powerful magnetic field to produce images of internal organs and body structures. Although any area of the body can be visualized by MRI, bone fractures are better visualized with a traditional x-ray or CT scan.
FIGURE 31-13a A closed magnetic resonance imaging (MRI) system (Courtesy of GE Medical Systems.)
❖ Patients with pacemakers or metal implants of any kind should not undergo an MRI, because the metal can interfere with the magnetic field. It is possible to burn the wires of the pacemaker unit and tissue surrounding the device. ❖ Objects containing metal, such as jewelry, eyeglasses, belts, hairclips, watches, clothing with zippers, wire bras, clothes with metal studs, and even some forms of makeup (mascara) can interfere with the magnetic field and cause burns to the patients. ❖ Credit cards or hotel keys with metallic strips can interfere with the magnetic field and should not be taken into the room where the procedure is performed. ❖ Removable dental work (such as partial dentures) and hearing aids contain metal and may cause burns to the patient.
FIGURE 31-13b Many patients are claustrophobic and cannot withstand a traditional MRI. For those patients, an open MRI can be used. (Courtesy of Barrington Medical Imaging, LLC, Cary, IL.)
F IELD SM A RTS Patients with pacemakers and internal defibrillators are unable to have MRIs, creating a huge dilemma for these patients when other diseases arise that require an MRI to make a proper diagnosis. Because of the increase of patients with these types of devices, medical equipment manufacturers are scurrying to come up with alternative solutions for these patients. Some
Ultrasound/Sonography Ultrasound is a diagnostic imaging procedure that does not use radiation but instead bounces highfrequency sound waves off the internal structures of the body, creating a sonogram or picture (Figure 31-14) of the internal structure that is being scanned. Ultrasound is used to detect abnormalities within the internal organs, such as gallstones, tumors, and heart defects. Because ultrasound waves do not harm a developing fetus, ultrasongraphy is often used to monitor the baby’s development during pregnancy. Ultrasound does not penetrate bone or any internal structures surrounded by bone, so it is not useful for assessing the brain, skeletal tissue, or the lungs. Ultrasound imaging is performed by specially trained personnel and can be performed in a medical office, hospital, or radiology facility. There is usually little to no preparation for an ultrasound procedure, but prep-
FIGURE 31-14 A sonogram image
manufacturers are now experimenting with filters that are compatible with MRI units and that will prevent these devices from picking up signals from the MRI equipment. This technology will prevent signal dysfunction to the patient’s equipment and prevent the patient from obtaining burns. This technology should be available sometime in the near future.
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aration instructions will vary depending on the structures being viewed. The patient should be instructed to wear loose-fitting, comfortable clothing because the procedure is conducted on bare skin. A conduction gel is placed on the patient’s skin and the transducer (a wand-like part of the instrument) is moved over the area. As the sound waves bounce off the internal structure, an image is displayed on the screen or oscilloscope. A hard copy of the image can also be printed. Refer to Figure 17-13 in Chapter 17 for a picture of a patient having an ultrasound performed.
NUCLEAR MEDICINE Nuclear medicine is a branch of medicine that uses radioactive isotopes for the purpose of diagnosing and treating diseases. Substances known as radionuclides, containing radioactive elements such as iodine and cobalt, are administered to the patient by mouth or by injection. Different areas of the body attract these isotopes, which can be detected on a special type of scan. Tumors and other types of abnormalities are detected as either “hot spots” where an unusually large amount
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FI E L D S M A R T S Patients receiving high concentrations of radionuclides may experience symptoms similar to those occurring from radiation therapy. The symptoms may include nausea, vomiting, diarrhea, irritation of the mouth, throat, or bladder, hair loss, and changes in the patient’s chromosomes.
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F IEL D S M A R T S Osteoporosis is usually only seen by x-ray when it has reached a very advanced stage. There are better tests for earlier detection of the disease, such as a bone density scan.
of radionuclides collect or “cold spots” where an unusually low amount of radionuclides collect. A “hot spot” may indicate the presence of a particular type of tumor, or may be found in areas that are inflamed, infected, or where trauma is present. A “cold spot” may indicate a lack of blood supply to an area or some forms of cancer. One example of a nuclear medicine scan is a bone scan. Radioactive isotopes are injected into the patient and the patient is asked to return in two to four hours for the actual scan to be performed. The isotopes accumulate in areas of the body where an abnormality, such as arthritis, exists and appear as dark areas or spots on the image (Figure 31-15). Radionuclides break down quickly, reducing unwanted side effects. In fact, the isotopes do not expose the patient to as much radiation as some traditional x-ray procedures.
RADIATION THERAPY Radiation therapy is used to treat inoperable tumors or areas from which a tumor has only been partially removed. This type of therapy is designed to target the malignant cells without harming the normal cells in the area. Radiation therapy can be administered through the skin to the target area in the body or by implanting radioactive “beads” or “seeds” inside the body and leaving them in place for a prescribed amount of time. This type of therapy interferes with the DNA of the malignant cells and slows down or halts their growth.
FIGURE 31-15 An image produced by a nuclear medicine bone scan
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Patients undergoing radiation therapy should be informed of possible side effects and signs and symptoms that should be reported following radiation therapy. These signs and symptoms may occur days to weeks following treatment and include: ❖ Redness of the skin that resembles a sunburn: Avoid using alcohol on the skin, avoid exposure to direct sunlight and other sources of heat, and do not lie on the reddened area. ❖ Hair loss: Some hair loss may occur if radiation burns are deep. Use mild shampoos and gently comb or brush the hair. ❖ Damage to the eyes: Signs of damage such as excessive tearing, dryness, injury to the lens, or conjunctivitis should be reported immediately. Artificial tears (eye drops) may be used along with antibiotics, if appropriate. ❖ Damage to the ears: The ears should be checked for blockage of the canal and bulging of the tympanic membrane (eardrum). Prevent falls due to dizziness and alert the office if there is any degree of hearing loss. Antibiotics may be administered if infection is present. ❖ Irritation of the mucosa of the mouth: If the mucosa is irritated, avoid spicy foods, smoking, and hot liquids. Sucking on ice chips may help to relieve some of the
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symptoms; however, frozen or cold foods and drinks may also be irritating. Try eating foods and drinking liquids that are room temperature. Irritation of the mucosa of the intestinal tract: Observe intake and output levels and report any diarrhea or vomiting. If diarrhea and vomiting are present, avoid dairy products and take OTC medications to help alleviate symptoms. If symptoms are not relieved with OTC products, the physician may need to write a prescription for the symptoms. Irritation of the mucosa of the urinary tract: Urine output should be measured and a urinalysis should be performed to determine if an infection is present. If so, antibiotics may be prescribed to treat the infection. An increase in fluids may help to decrease the symptoms. Bone marrow and lymph tissue damage: Report unusual bleeding, and watch for signs of anemia such as extreme fatigue, shortness of breath, and unusual bruising. The provider will perform blood counts on a regular basis and may start the patient on antibiotics to protect the patient from infection. Nervous system symptoms: Report any signs of pain, incontinence, slurred speech, cognitive dysfunction, dizziness, or weakness and tingling in the arms and legs.
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Chapter Summary Diagnostic imaging, which includes radiology procedures, ultrasonography, and nuclear medicine, makes it possible for providers to view internal structures within the body. The medical assistant should be knowledgeable regarding the indications for x-ray procedures, including their uses for diagnosis and treatment. The ability of the medical assistant to provide accurate instructional information will be important for patient compliance and better results. When taking x-rays, medical assistants must institute safety measures to protect both the patient and themselves. Never take shortcuts, and avoid the need to retake x-rays because appropriate measures were not taken to get it right on the first try.
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FIELD APPLICATION CHALLENGE A 46-year-old Hispanic male comes to the family practice facility where you work. The patient has a productive cough of two weeks, a low grade fever, and complains of chest pain when coughing. Sleep has been difficult. The English language is difficult for the patient. The provider has ordered a PA and lateral chest x-ray on the patient.
1. How will you describe the procedure to the patient? What techniques can be used to enhance the communication process? 2. What must be considered when scheduling the patient’s x-ray? 3. What might the x-ray show?
Chapter Assessment 1. Which of the following radiological procedures requires no patient preparation? a. Upper GI b. Lower GI c. Chest x-ray d. X-ray of the hand e. Both c and d
6. Which part of the body is examined during an angiogram? a. Joints b. Blood vessels c. Vertebrae d. Intestines
2. Which of the following would be an example of a contrast medium? a. Barium cobalt b. Barium sulfate c. Barium sodium d. Barium citrate
7. Which radiological procedure provides the radiologist with thin cross-sectional images of the body? a. Bone scan b. CT scan c. Nuclear medicine scan d. MRI
3. In which of the following x-ray positions would the patient’s chest be against the film? a. Lateral b. AP c. PA d. Oblique
8. Which of the following items must be worn by health care workers who perform x-rays? a. Lab coat b. Dosimeter c. Oximeter d. Goggles
4. Which of the following x-ray procedures would require a contrast medium? a. KUB b. IVP c. Foot d. Abdominal
9. What does a cholangiography evaluate? a. Bile ducts b. Liver c. Gallbladder d. Both a and b e. All of the above
5. All of the following can be side effects of radiation therapy except: a. hair loss. b. nausea. c. blood loss. d. none of the above.
10. All of the following procedures require special patient preparation except: a. upper GI. b. lower GI. c. MRI. d. small bowel series.
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Web Activities 1. Search the Internet for a local hospital or facility that performs x-rays and compile a list of special patient preparation for the following procedures: cardiac catheterization, pelvic ultrasound, full body CT scan with contrast, and upper GI series. 2. Search the Internet and locate three companies in your area that recycle x-rays. Provide a detailed list of services that each company provides.
CONNECTION Using your StudyWARE CD-ROM: ❖ Complete the Hangman activity for this chapter. ❖ Complete the Crossword Puzzle for this chapter. ❖ Complete the Quiz for this chapter in Test Mode.
C H A P T E R
Fundamentals of Pharmacology Chapter Outline Drug Origins Drug Sources Medicinal Uses of Drugs Drug Classifications Pharmacodynamics Dose Response Drug Actions Pharmacokinetics Drug Effects Factors That Affect Drug Actions Drug Names Medication Tasks Regulations and Legal Classifications of Drugs Controlled Substances The Medication Order/Prescription Writing Prescription Abbreviations
Rules for Writing or Calling in Prescriptions for Controlled Substances Tamper-Resistant Prescription Pads Drug Resources The Physician’s Desk Reference U.S. Pharmacopecia/National Formulary Drug Product Package Inserts Drug Resources on the Internet Safe Drug Administration Seven Rights of Drug Administration Safety and Continuity during Medication Administration Routes of Medication Administration Enteral Routes Parenteral Routes
32 Essential Terms administer affinity agonist anaphylaxis antagonist bioavailability buccal dispense drug drug ceiling drug interaction efficacy enteral local reaction medicinal parenteral pharmacodynamics pharmacokinetics pharmacology prescribe prophylactic receptor side effect continues
FUNDA MENTALS OF PHARM ACOLOGY
KEY COMPETENCIES
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CAAHEP
ABHES
Maintain Medication and Immunization Records
III.C.3.c.4.h
VI.A.1.a.4.n
Creating a Prescription
III.C.3.c.4.g
Administration of Oral Medications
III.C.3.c.4.g
VI.A.1.a.4.m
Administration of Topical Medications
III.C.3.c.4.g
VI.A.1.a.4.m
Administration of Transdermal Medications
III.C.3.c.4.g
VI.A.1.a.4.m
Administration of Rectal Medications
III.C.3.c.4.g
VI.A.1.a.4.m
sublingual systemic reaction therapeutic effect therapeutic index topical transdermal patch
779
Developmental Objectives After completing this chapter, you should be able to: 1. Correctly spell and define the essential terms. 2. List and describe five different sources of drugs. 3. List five different uses of drugs. 4. List the different drug classifications and their definitions and provide examples from each group. 5. Describe how drugs attach themselves to drug receptor sites and at what point the drug exerts its affect on the patient. 6. Describe dose response and list factors that can affect a patient’s response to particular medications. 7. List and describe four processes that affect drug plasma levels. 8. List and define three different names by which a drug may be referred. 9. Describe the following terms and designate which health care professionals can perform each task: prescribe, administer, dispense. 10. List the administration that establishes standards for pharmaceutical companies to follow in the development and sale of prescribed and over-the-counter medications. 11. Describe the reason for the Controlled Substance Act and describe what agency is responsible for enforcing measures within this act. 12. Describe the five schedules used to differentiate the various classifications of controlled substances and describe how prescriptions may be relayed to a pharmacist for each schedule. 13. Describe the following forms and list their uses: DEA Form 222, DEA Form 224, DEA Form 106, DEA Form 41. 14. List the types of records that should be kept in regards to controlled substances and how long they are to be kept. 15. Define the term prescription and list its parts. 16. List and describe the various types of drug references that are available to research various drugs.
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17. List and describe the seven rights of drug administration.
Throughout the early history of pharmacy, herbalists, physicians, and priests (whose roles often intertwined) all played active roles in apothecary functions. However, these individuals had very little training in apothecary studies, placing citizens seeking their guidance in harm’s way. It wasn’t until the Middle Ages that the roles of these practitioners diverged and the practice of pharmacy became a specialty. The first college of pharmacy originated in 1821, and the American Pharmaceutical Association (APhA) was founded in 1852. During the early years of pharmacy, drugs didn’t have to meet specific standards before being introduced to the public; hence, drug quackery was quite common. As a result of drug efficacy and safety concerns, drug laws were developed by the early 1900s to protect the public against drug scams and to promote overall drug safety. Today, a drug must go through rigorous testing before being introduced to consumers. Scientists use a variety of sources to produce drugs including plants, minerals, animals, and synthetics.
18. List the two major routes of drug administration and list and describe all the routes within each major route.
Introduction A drug is any substance that produces a change in the function of a living organism. Pharmacology is the study of drugs, including their origin, nature, properties, and effects upon living organisms. A drug’s efficacy (effectiveness) and benefits have to be measured and compared to its risks in order to determine its viability. Medical assistants must have a basic understanding of the fundamentals of pharmacology including drug uses, forms, classifications, and routes of administration. Becoming familiar with the effects that drugs have on the body and the physiological variables that can alter their performance will enable the medical assistant to properly administer drugs and provide appropriate education for patients. In addition, the medical assistant must be familiar with (1) state and federal drug laws that dictate procedures that must be followed when working with special categories of drugs and (2) state delegation laws dictating who has authority to delegate pharmacological tasks to the medical assistant.
Drug Sources There are a variety of sources that can be used to manufacture drugs (Figure 32-1). Some of the first drug sources were plants, fruits, and vegetables. Further research revealed that certain extracts from animals were useful in alleviating patient symptoms or replacing missing chemicals. Today, bioengineering techniques allow chemists to modify particular genes within plants to perform certain functions or to alleviate particular side effects associated with their use.
DRUG ORIGINS One of the first historical records of drugs comes from Babylonia in the form of textbooks found on clay tablets tracing back to 2600 B.C. These tablets contained inscriptions describing symptoms of a disease, a drug formula that could be used as a remedy for the disease, compounding instructions, and a chant or spell that could be used to enhance the formula’s effectiveness.
Plant Sources Medicinal use of plants for treating disease processes or disorders has been the foundation of pharmacological therapy for thousands of years. Studying the leaves, stems, roots, blossoms, or fruit of certain plants led to the discovery of their medicinal properties and func-
FIGURE 32-1 Drugs are
IA 1
obtained from a variety of sources: (a) plant, (b) animal, (c) mineral, and (d) synthetic, as well as bioengineering (not shown).
H
1
Li 11
3
K 37
5
(a)
(b)
20
IIB
IVB 22
21
Ca Sc 38
56
40
39
Y 57
Fr
88
89
VB 23
Ti Zr 72
Cs Ba *La Hf 87
7
12
Rb Sr 55
6
Be
Na Mg 19
4
IIA 4
3
2
104
Ra +Ac Rf
(c)
VIB 24
V 41
Cr 42
Nb Mo 73
Ta 105
74
W 106
Ha Sg
(d)
FUNDA MENTALS OF PHARM ACOLOGY
tions. One example of a plant source used today is the genus Digitalis, which includes the perennial and Grecian foxglove plants, which are used to make digitalis and digoxin (drugs used to treat congestive heart failure). Other examples include ergot, a particular type of fungus that grows on grass and cereal grain, once used as a uterine stimulant and now used in the treatment of migraines, and opium, which originates from the poppy plant and is the key ingredient for all narcotics. Herbal medications come from a variety of plants as well and should be listed in a patient’s drug history.
Animal Sources Animals are sometimes used as sources for drugs. Drugs derived from animal sources include insulin, thyroid medications, cortisone, and adrenaline. These essential extracts are obtained from the tissues of the pancreas and adrenal glands of particular animals. Premarin, a conjugated estrogen, is made by extracting hormones from the urine of a pregnant mare and is used to treat menopausal symptoms. Even the eggs of a hen are used to develop certain vaccines. Animal sources are contraindicated when the patient has an allergy to any of the products or by-products used to develop the drug.
Mineral Sources Minerals, such as silver nitrate and sulfur, are highly purified forms of elements that are used to treat specific diseases. A sulfonamide (a specific type of antibiotic) is an example of a drug that comes from a mineral source and is commonly used to treat bacterial infections of the urinary tract. The antipsychotic drug lithium carbonate is another example of a drug made from a mineral source and is used to treat bipolar disease. Due to the possibility of drug interactions, all minerals, including over-the-counter (OTC) products, should be included in the patient’s drug history.
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F IEL D S M A R T S Patients receiving flu vaccine should be thoroughly questioned about chicken egg allergies before administration. This is because the vaccine is developed using the eggs of hens. Administration of these products to a patient with an allergy could cause the patient to go into anaphylaxis, a severe life-threatening condition caused by the allergy.
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FI E L D S M A R T S Sulfa is one of the leading minerals known to stimulate hypersensitivity reactions in the body.
Synthetic Origins Synthetic forms of drugs are created in pharmaceutical laboratories by experimenting with different chemicals. Scientists are able to create new drugs or compounds that are identical to natural drugs by altering and combining chemicals using a variety of different methods. One advantage of producing synthetic drugs is the ability to standardize the doses and to alter substances that may cause serious side effects. Synthetic drugs are usually more economical to manufacture than those coming from natural sources, resulting in less expense to the patient.
Bioengineering Genetic engineering is the latest process that is used to manufacture drugs. All living structures (plants, animals, and people) have the exact same DNA molecular structure consisting of six basic components—a phosphate, a sugar, and four bases. Recombinant technology takes genetic information from two different organisms and combines them together. These drugs are produced by utilizing the DNA within a bacterium or other microorganism and performing gene splicing to produce hybrid forms of drugs. By removing the bacterial walls of an Escherichia coli bacterium and combining it with an insulin gene, the drug Humulin (a form of human insulin) is made. The cells duplicate rapidly, making billions of new cells capable of producing insulin. Bioengineering has been practiced for many years in the agricultural and horticulture industry.
MEDICINAL USES OF DRUGS Drugs are prescribed to patients for a variety of purposes. Listed below are the five medicinal uses of drugs: ❖ Therapeutic: A substance used in the treatment of a condition to relieve symptoms. An example is using aspirin to relieve symptoms of a headache. ❖ Diagnostic: A medicinal product used in combination with radiography and other imaging procedures to detect abnormalities, such as lesions and
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tumors, and to check how well a specific organ is functioning. An example of a diagnostic drug used to detect GI abnormalities is barium sulfate. Radioactive iodine is a radionuclide that is used to check thyroid function. ❖ Curative: A medication that helps to remove an agent that causes disease. Antibiotic therapy is an example of a curative drug because of its ability to destroy bacteria. ❖ Replacement: These are agents used to replace chemicals that are deficient or missing in the body, such as insulin and other hormones. Vitamins and minerals are examples of other substances that are commonly used in replacement therapy. ❖ Preventative (also termed prophylactic): These substances are used to prevent or lessen the sever-
ity of a disease. Examples include immunizing agents such as vaccines and antibiotics that are given prior to surgical procedures to reduce the risks of infection.
DRUG CLASSIFICATIONS Drugs are categorized under different classifications and may be segregated by their actions upon the body, the change they produce in cellular activity, or by the body system they affect. Drugs that have multiple effects may be found under several classifications. Table 32-1 lists common drug classifications and their actions. Refer to Appendix E for a list of the top 50 drugs and their classifications.
TABLE 32-1 Drug Classifications and Their Actions CLASSIFICATION
ACTION
EXAMPLES
Analgesic
Relieves pain
Nonnarcotic examples: Tylenol (acetaminophen) Bayer, Aspro, Dispril (aspirin) Advil and Motrin (ibuprofen) Narcotic examples: Hydrocodone w/APAP
Anesthetic
Produces a lack of feeling; may be local or general
Local anesthetics: Novacaine (procaine HCL) Xylocaine (lidocaine HCL) General anesthetic: Ultane (sevoflurane)
ACE inhibitor or angiotensionconverting enzyme inhibitors
Treats hypertension
Aaltace (ramipril) Prinivil (lisinopril) Vasotec (enalapril)
Antacid
Neutralizes stomach acid
Mylanta, Maalox, Zantac, Prilosec
Antiacne
Treats acne
Accutane (Isotretinoin) Differen Gel (adapalene gel)
Antianginal
Relieves the symptoms of angina
Imdur (isosorbide mononitrate) Isordil (isosorbide) Nitrostat (nitroglycerin)
Antianxiety
Relieves anxiety and muscle tension
Librium (chlordiazepoxide HCL) Valium (diazepam) Xanax (alprazolam)
Antiarrhythmic
Controls cardiac arrhythmias
Norpace (disopyramide) Procan SR (procainamide) Quinidine Cardioquin
FUNDA MENTALS OF PHARM ACOLOGY
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TABLE 32-1 Drug Classifications and Their Actions (continued) CLASSIFICATION
ACTION
EXAMPLES
Antibiotic
Inhibits or destroys bacteria
Ceftin (cefuroxime) Cleocin HCI (clindamycin HCL) Levaquin (levofloxacin)
Anticholinergic
Reduces muscle spasms in the bladder, lungs, intestines, and eye muscles (also known as an antispasmotic)
AtroPen (atropine sulfate) Ditropan (oxybutynin) Donnatal (scopolamine sulfate)
Anticoagulant
Prevents or delays blood clotting
Coumadin (warfarin sodium) Dicumarol (heparin sodium) Lovenox (enoxaparin sodium)
Anticonvulsant
Prevents or relieves convulsions
Klonopin (clonazepam) Neurontin (gabapentin) Tegretol (carbamazepine)
Antidepressant
Prevents or relieves symptoms of depression
Celexa (citalopram) Effexor XR (venlafaxine) Wellbutrin-SR (bupropion)
Antidiabetic
Helps to lower blood glucose levels
Oral hypoglycemics: Actos (pioglitazone) Glucophage (metformin) Micronase (glyburide) Forms of insulin: Humulin R (short acting) Humulin N (long acting)
Antidiarrheal
Counteracts diarrhea
Kaopectate (kaolin/pectin) Pepto-Bismol (bismuth subsalicylate)
Antiemetic
Counteracts nausea and vomiting
Compazine (prochlorperazine) Dramamine (dimenhydrinate) Phenergan (promethazine)
Antiflatulant
Relieves gas and bloating in the GI tract
Gas-X (simethicone) Mylicon—infant drops
Antifungal
Kills or prevents the growth of fungi and yeast
Diflucan (fluconazole) Monistat (miconazole) Nizoral (ketoconazole)
Antigout agent
Prevents or lessens the occurrence of gout attacks
Benemid (probenecid) Zyloprim (allopurinol)
Antihistamine
Counteracts the effects of histamine in the body; helps to relieve symptoms of allergic reactions
Allegra (fexofenadine) Claritin (loratidine) Zyrtec (centirizine)
Antihyperlipidemic or cholesterollowering agent
Helps to decrease cholesterol or lipid levels
Lescol (fluvastatin) Lipitor atorvastatin calcium Zocor (simvastatin)
Antihypertensive
Reduces high blood pressure
Accupril (quinapril) Altace (ramipril) Vasotec (enalapril) continues
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TABLE 32-1 Drug Classifications and Their Actions (continued) CLASSIFICATION
ACTION
EXAMPLES
Anti-inflammatory
Reduces or relieves inflammation
Advil, Motrin (ibuprofen) Bextra (naproxen) Celebrex (celecoxib)
Antimanic
Treats manic disorders
Eskalith (lithium)
Antimigraine
Relieves migraines
Imitrex (sumatriptan)
Antineoplastic
Destroys or inhibits the growth of malignant cells
Cytoxan (cyclophosphamide) Myleran (busuflan)
Antiparkinson’s agent
Treats symptoms associated with Parkinson’s disease
Sinemet (carbidopa/levodopa)
Antiprotozoal
Treats protozoal infections
Flagyl (metronidazole)
Antipsychotic
Treats schizophrenia and other associated brain disorders
Haldol (haloperdol) Seroquel (quetiapine) Zyprexa (olanzapine)
Antiretrovial
Treats HIV infections
Retrovir (zidovudine)
Antispasmotic
Relieves cramps or spasms of the stomach, intestines, and bladder
Bentyl (dicyclomine) Levsin (hyoscyamine)
Antitussive
Prevents or relieves cough
Benylin (cough syrup with codeine) Tessalon (benzonatate)
Antiulcer
Treats ulcers of the stomach and upper intestine
Prevacid (lansoprazole) Priolsec (omeprazole) Protonix (pantoprazole)
Antiviral
Works against a viral infection
Symmetrel (amantadine) Zovirax (acyclovir)
Bone resorption inhibitor
Prevents and treats osteoporosis
Evista (raloxifene) Fosamax (alenfronate)
Bronchodilator
Eases breathing by dilating the bronchial tubes
Atrovent (ipratropium) Combivent (ipratropium, albuterol) Proventil (albuterol)
Cardiac glycoside
Strengthens the heart muscle; treats congestive heart failure
Digitek (digitoxin) Lanoxin (digoxin)
Central nervous stimulant
Treats attention-deficit/hyperactivity disorder
Adderall (amphetaminedextroamphetamine) Strattera (atomoxetine HCl)
Contraceptive
Prevents conception
Injectable: Depoprovera (medroxyprogesterone) Oral: Yasmin (ethinyl estradiol/drospirenone)
Corticosteroid
Treats inflammation
Cortone (cortisone) Flovent (fluticasone)
FUNDA MENTALS OF PHARM ACOLOGY
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TABLE 32-1 Drug Classifications and Their Actions (continued) CLASSIFICATION
ACTION
EXAMPLES
Cough expectorant
Liquefies mucus and promotes its removal
Robitussin (guaifenesin) (terpin hydrate)
Decongestant
Reduces nasal congestion and swelling
Afrin (oxymetazoline) Sudafed (pseudoephedrine)
Diuretic
Increases the output of urine
Dyrenium (triamterene) Lasix (furosemide)
Emetic
Facilitates vomiting
Syrup of Ipecac
Hemostatic
Assists in blood coagulation or clotting
vitamin K thrombin
Histamine (H2) receptor antagonist
Blocks all phases of gastric acid secretion
Tagamet (cimetidine)
Hormone replacement
Replaces hormones that are diminished (menopausal symptoms, thyroid disorder, etc.)
Premarin (conjugated estrogen) Prempro (conjugated estrogen/ progesterone)
Hypnotic
Produces sleep
Ambien (zolpidem)
Immunosuppressant
Suppresses the immune system (RA and transplant patients)
Neoral, Dandimmune (cyclosporine)
Laxative
Loosens stools and promotes normal bowel evacuation
Dulcolax (bisacodyl) Colace (docusate)
Miotic
Contracts pupils of the eyes
Pilacar ophthalmic solutions
Mydriatic
Dilates pupils of the eyes
Neo-Synephrine (phenylephrine)
Muscle relaxant
Aids in relaxation of skeletal muscles
Flexeril (cyclobenzaprine) Robaxin (methocarbamol) Soma (carisoprodol)
Nonsteroidal anti-inflammatory drug (NSAID)
Relieves mild to moderate fever, pain, and inflammation
Aleve (naproxen) Celebrex (celecoxib) Relafen (nabumetone)
Sedative, hypnotic, tranquilizer
Produces a calming effect; used to treat insomnia
Ambien (zolpidem) Lunesta (eszopiclone)
Thrombolytic agents
Aids in dissolving blood clots that already exist
Activase (alteplase) Streptase (streptokinase)
Vasodilator
Produces relaxation of blood vessels; lowers blood pressure
Natrecor (nesiritide) Nitrostat (nitroglycerin) Nesiritide
Vasopressor
Produces constriction of blood vessels; elevates blood pressure and cardiac output
Intropin (dopamine)
Note: Drugs that are capitalized indicate trade names. Drugs in parentheses indicate generic names.
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PHARMACODYNAMICS The term pharmacodynamics refers to the study of the effects of drugs on living organisms. Drugs exert a forceful and specific action in the body by forming a bond to protein molecules or chemical groups found within a cell or on its surface. These bonding proteins or sites are referred to as receptors, each having a unique structural design. Receptors are normally activated by neurotransmitters or hormones (Figure 32-2a). To bind correctly with cell receptors, drugs must have a similar or complementary chemical structure to that of its receptor. Affinity is a measurement of how tightly a drug attaches or binds to a receptor. This binding creates a signal for the cell to function or respond in a particular manner; the tighter the binding, the better the result. Drugs that bind to receptors and affect cell response are referred to as agonists (Figure 32-2b), while drugs that prevent cell response are called antagonists (Figure 32-2c). Agonists mimic or enhance the action of the receptor, whereas antagonists block or inhibit the action of a receptor. Albuterol is an example of a short-acting beta2agonist used in the treatment of acute asthma. Alb-
FIGURE 32-2a The body’s natural chemicals or neurotransmitters are specially designed to lock into the cell’s receptor site, stimulating the cell to take a specific action. Before Drug
Drug manufacturers perform a proliferation of testing prior to a drug’s distribution to determine its risk-tobenefit ratio. The manufacturer must also determine the drug’s therapeutic index, or the range between the therapeutic dose of a drug and the dose at which the drug becomes toxic (Figure 32-3). Some drugs, such as non-opioid pain relievers, have what is referred to as a drug ceiling. A drug’s ceiling is the maximum dose at which the drug will provide its greatest effect. Taking higher doses than those listed as the maximum dose on the drug’s label will provide no further therapeutic value and in some cases may cause harm to organs such as the kidneys and liver. Opioid drugs such as morphine do not have a ceiling effect and are used in patients that are terminally ill or to manage patients who are in excruciating pain.
FIGURE 32-2c An antagonist drug
works with the body’s natural chemicals by enhancing cellular activity.
works against the body’s natural chemicals by blocking the cell’s receptor site so that the neurotransmitters cannot get through.
Hormone Neurotransmitter
Receptor site
Normal chemical activity within the cell
Dose Response
FIGURE 32-2b An agonist drug
Neurotransmitter
The cell
uterol acts on the beta2-adrenergic receptors resulting in relaxation of muscles lining the airway, stimulating the bronchial tubes to dilate. Zofran is an example of a serotonin antagonist. It works by blocking the effects of serotonin produced in the brain and stomach and helps to prevent nausea and vomiting in patients receiving chemotherapy.
Antagonist Drug
Agonist Drug
Agonist drug Antagonist drug
No chemical activity Increase in chemical activity
Notice how the antagonist blocks the receptor site
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FUNDA MENTALS OF PHARM ACOLOGY
787
30
20 Minimum effective concentration (MEC) 10
Drug concentration in plasma
Drug concentration in plasma
Minimum toxic concentration (MTC)
Peak plasma level
Time to peak (approximately 1.6 hours)
0 4
12
20 Time (hours)
28 0
1
2
6
5 4 3 Time (hours)
7
FIGURE 32-3 Notice the separation between the therapeutic dose (minimum effective concentration) and the concentration of the drug at which the drug becomes toxic.
FIGURE 32-4a The time it takes for the drug to reach its peak
The effect that a drug will have at the site of action is directly related to the amount of the drug received and how it is administered. The bioavailability of a drug refers to the extent to and the rate at which the drug enters the blood plasma and is made available at the site of action. Figure 32-4a is an example of a dose response curve illustrating the bioavailability of a hypothetical drug (taken in oral form) and the point that the drug should reach its peak plasma level, or level of highest concentration. This example illustrates that the drug should start being released within minutes of consumption and should peak in concentration approximately 1.6 hours following consumption. All intravenous drugs have 100% bioavailability, meaning that the entire drug is automatically released into the bloodstream upon injecting into the vein and available at the site of action (Figure 32-4b). Notice how the drug’s peak concentration occurs immediately following administration. The bioavailability of oral medications may be influenced by acids and enzymes in the stomach, foods in the stomach, and any pathological conditions associated with organs of digestion. This process may take anywhere from several minutes to days depending on the drug’s consistency when the drug is given by mouth. Generally speaking, the order in which drugs are absorbed within the digestive tract are as follows: solutions, suspensions, capsules, tablets, coated tablets.
Drug concentration in plasma
plasma level following oral ingestion of the drug
Peak plasma level
0
1
2
3
4
5
6
7
8
Time (hours)
FIGURE 32-4b The time it takes for the drug to reach its peak plasma level following single-bolus intravenous administration
Once a drug reaches its therapeutic level within the blood plasma, the patient is able to reap its full benefits. To jump-start this process, the physician may choose to give the patient a loading or priming dose of the medication. In this scenario, the patient
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is initially given higher doses of medication than the usual maintenance dose. This practice assists in getting the drug to a therapeutic level in a quicker time frame. Once the drug reaches the therapeutic level in the blood plasma, the dose is tapered off to a standard maintenance dose.
Variables Affecting the Drug’s Blood Plasma Level Four processes that drugs go through after being administered into the body include: 1. Absorption: This is the process by which the drug passes into the body tissues or body fluids. This process depends on how the drug was administered, gastrointestinal function (when the drug is taken orally), and the chemical makeup of the drug. 2. Distribution: The process by which the drug is transported from the blood to the intended site of action. 3. Biotransformation: This is the process in which the drug is chemically altered and undergoes changes in order to be utilized as intended by the body. This process occurs mainly in the liver. 4. Elimination: The process by which the drug is excreted from the body. Numerous drugs are eliminated through the kidneys. Elimination can also occur through the gastrointestinal tract, the respiratory tract, the skin, the mucous membranes, or even the mammary glands. The concentration of a single dose of an oral medication increases until the drug plasma level reaches its peak. As the drug is broken down and eliminated from the body, the drug plasma level declines, thus weakening its effects.
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C R I T I C A L T H I N K I NG CHALLENGE A patient calls and states that her headache is not subsiding after taking the maximum dose of Tylenol. The patient asks if it would be okay to take one more capsule. 1. Do drugs like Tylenol have a drug ceiling? 2. What are potential risks of taking a dose beyond the recommended maximum dose? 3. What might be an appropriate response to give to the patient?
Drug Actions Drugs may be grouped by the type of action they produce in the body. Drug actions include the following: ❖ Local action: The drug acts on the area of tissue in which it is administered. Examples include topical medications applied to a joint to relieve pain or a local anesthetic injected into an area where a surgical procedure is going to be performed for numbing purposes. ❖ Remote action: The drug has an effect in a different location of the body than where it was administered, such as a nerve block (for instance, injecting analgesics and narcotics along the spine to block the pain of labor). ❖ Systemic action: The drug is absorbed into the bloodstream and carried to other parts of the
PAT I E N T T U T O R Patients taking drugs with a narrow therapeutic index must be continually monitored to make certain that the drug plasma levels are within the therapeutic range. Patients should receive education on the importance of taking drugs as directed and should be advised of the importance of routine drug monitoring. Drug blood plasma levels below the therapeutic range will
prevent the patient from experiencing the drug’s full benefits. Levels higher than the therapeutic range may cause significant organ damage. Examples of drugs that should be routinely monitored include: Digoxin, Phenobarbital, Theophylline, Lithium, Cyclosporin, and Ritonavir. Any critical lab values should be given to the physician for immediate review.
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body as with oral medications, injectables, and suppositories. A large percentage of the drugs that are administered in ambulatory settings are systemic medications.
PHARMACOKINETICS Pharmacokinetics is a term that describes how the body reacts to a drug, which depends on specific variables of the individual taking the drug, the form of the drug, the chemical composition of the drug, and the route or mode of administration.
Drug Effects While the primary effects of therapeutic drugs may be beneficial, other effects from particular drugs can be detrimental. The combination of various drugs, chemicals, or foods can change the affect that a drug has on the body. Different effects that a drug may have in the body include: ❖ Therapeutic effect: The desired effect that a drug has on the body. ❖ Side effect: A secondary effect in addition to the therapeutic effect. Some side effects are therapeutic and end up becoming another use for the drug. However, most side effects are unpleasant and may even be harmful (these are often referred to as adverse effects). Harmful or even deadly side effects may be the result of an incorrect dosage and often occur at the beginning of treatment, when changes are made to the dose, or when the drug is discontinued. ❖ Drug interaction: This occurs when one drug diminishes the affects of another drug or increases the affects of another drug.
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F IEL D S M A R T S Epinephrine is a drug that is commonly given to patients experiencing signs of anaphylaxis. It helps to reverse anaphylaxis. Epi-Pens or Epinephrine should be stocked in every room where medications are administered. Remember never to give a drug without an order from the physician. You can however, draw up the medication.
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❖ Drug allergy: An allergy to a drug occurs when the body forms antibodies against specific chemicals in a drug, stimulating an allergic response. A less severe allergic reaction is referred to as a local reaction, such as occurs when the patient experiences pruitis (itching), edema (swelling), and erythema (redness) at the site at which the medication was administered. A systemic reaction occurs when the entire body is involved and may include urticara (hives) or a rash over the entire body. Anaphylaxis, an advanced systemic reaction, may include the systemic signs above as well as bronchial constriction, swelling of the tongue or throat, and an inability to breathe. This is a life-threatening emergency that should be reported to the physician immediately. Chapter 35 addresses first aid procedures for assisting patients in anaphylaxis.
Factors that Affect Drug Actions There are other factors that can affect the anticipated response that each patient may have to a drug. Table 32-2 lists and describes these factors.
DRUG NAMES A single drug may have up to three names—chemical, generic, or trade: ❖ Chemical name: This is the name assigned to a drug that comes from its chemical formula. The chemical formula includes letters and numbers that illustrate the molecular structure of the compound. For example, C9H8O4N is the chemical formula for aspirin. The chemical name for aspirin is acetylsalicylic acid. ❖ Generic name: This is the drug’s official name, which is assigned by the United States Adopted Names (USAN) Council. A generic drug contains
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FI E L D S M A R T S A great Web site that the patient can use to check for drug interactions is http://www.drugs .com. Patients can insert all of their prescribed and over-the-counter medications and an alert box will come up when there are potential drug interactions.
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TABLE 32-2 Factors That Affect Drug Actions Age
Newborns have immature body systems, whereas an elderly person’s organs are diminishing in function. As drugs are metabolized differently in these special populations, patients and caregivers of patients should be educated on the importance of taking or administering medication as prescribed and symptoms or signs that could be an indicator for alarm in these special populations.
Body weight
Adult medications are calculated based on the average adult weight of 150 pounds. Pediatric medications are calculated based on body surface area or the child’s weight. The physician will need to make adjustments in dosages to match the patient’s specifications.
Compliance
If the patient does not take the drug in the manner in which it is intended, the patient will not receive the maximum benefits. Education is essential to promote compliance.
Disease
Patients may experience an adverse response to certain drugs if a disease has complicated their ability to absorb or excrete the drug properly. For example, patients with renal or liver disease may be unable to metabolize or excrete the medication properly. Chronic use of acetaminophen, ibuprofen, aspirin, antibiotics, steroids, and statin (anticholesterol) drugs may lead to kidney or liver failure.
Gender
Drugs may affect men and women differently due to muscle/fat ratios and the presence of certain hormones. Pregnant women have to be extremely cautious when taking medication to avoid damage to the developing fetus.
Idiosyncrasy
Some patients may react to a drug in an unusual manner; for example, a patient takes a tranquilizer to rest and feel less anxious but instead the opposite occurs.
Interactions from other drugs or foods
Sometimes interactions from other drugs or food can change the desired outcome of drug therapy. For example, the effects of oral hypoglycemics may be diminished when the patient takes both an oral hypoglycemic and specific types of diuretics. Female patients taking certain antibiotics or antifungals in combination with oral contraceptives may be at risk of becoming pregnant due to an interaction problem between the two.
Timing
The time of day that the drug is taken may have an impact on its effect. Gastric activity can affect the absorption of some drugs, so labels are placed on the medication bottle to instruct the patient when to take the drug (such as before or after meals). Drugs affecting the body’s diurnal rhythms (day/night processes) should be given at times to match the body’s natural responses. For instance, sedatives should be taken in the evening and stimulants should be taken at the beginning of the day.
Tolerance
Tolerance to a drug occurs when the body becomes overly adapted to the drug and fails to respond to the drug at the cellular level. Acquired tolerance occurs after taking a particular drug for an extended period of time.
the same ingredients as the trade drug but is usually much less expensive. The generic name of a drug will start with a lowercase letter, whereas the trade name will begin with a capital letter—for example, aspirin is the generic name for Bufferin, Ascriptin, and Ecotrin, and acetaminophen is the generic name for Tylenol. Generic drugs may be manufactured by more than one drug company, though each company produces the drug under its
own unique brand or trade name (while keeping the generic name the same). ❖ Trade name: This is the name under which a drug is registered with the U.S. Patent Office and is characterized by the symbol ® following the name. This name is used exclusively by the pharmaceutical company that produces the drug. When a drug is first introduced, it is protected by patent, which means that no other manufac-
FUNDA MENTALS OF PHARM ACOLOGY
turer can produce the same drug until the patent is expired. During this time, there are no generic substitutes available. Examples of some trade names include: Celebrex (celecoxib), Keflex (cephalexin), and Lasix (furosemide).
MEDICATION TASKS In order to perform medication tasks, health care workers must be familiar with common terms used in medication tasking: ❖ Prescribe: To order a medication from the pharmacy, usually by prescription ❖ Dispense: To personally hand the patient a medication to take later; in ambulatory care, drug samples and stock samples are commonly dispensed to patients. ❖ Administer: To prepare and personally give the patient a medication through any method, at the point of care Physicians are licensed to prescribe, dispense, and administer medications for their patients. Depending on the state, midlevel practitioners such as nurse practitioners and physician assistants may also participate in these tasks. The medical assistant cannot prescribe or order medications but may be able to dispense or administer certain types of medications or create and call in prescriptions with a direct order from the physician.
REGULATIONS AND LEGAL CLASSIFICATIONS OF DRUGS For the safety of the consumer, the U.S. Food and Drug Administration (FDA) establishes standards for pharmaceutical companies to follow in the development and sale of prescribed and OTC medications.
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F IEL D S M A R T S Medication delegation rules will vary from one state to another. Always check the delegation rules in the state in which you are employed before accepting medication orders from a midlevel practitioner.
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Drug companies must gain FDA approval before their drugs can be sold to consumers. This process is lengthy and very costly. The approval process incorporates a variety of testing measures to ensure the quality and safety of the drug, including laboratory testing, animal testing, and human testing performed on volunteers. Upon FDA approval, the manufacturer is awarded patent protection for 20 years (under special conditions, the manufacturer can apply for a five-year patent extension). After the initial copyright period has elapsed, the drug patent is released and other manufacturers may produce the drug under a different trade name. Supplemental mineral products and other herbal supplements are not required to go through the same rigorous testing as other drugs. In many cases, the labeling information and packaging does not accurately depict the supplement’s contents. To help ease the mind of consumers, some manufacturers voluntarily have these products tested at their own expense. The USP seal of approval (Figure 32-5) assures consumers that these products have been properly tested and that the products are safe. Encourage patients to look for this label when purchasing these products.
Controlled Substances Providers that prescribe, dispense, or administer controlled substances must be registered with the U.S. Drug Enforcement Administration (DEA), a part of the Department of Justice. The DEA, established in 1973, is responsible for enforcing U.S. controlled substance laws and regulations. FIGURE 32-5 The USP symbol assures consumers that products have been properly tested and that the contents on the inside of the container match the label information on the outside.
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The Controlled Substances Act (CSA) defines drugs or substances that may have the potential for illegal use or abuse. Based on CSA guidelines, controlled substances are divided into five schedules, according to their addictive properties and degree of abuse. It is important to stay up to date with this schedule, as it is updated frequently. Table 32-3 lists each of the schedules, the drug’s potential for abuse in that schedule, accepted medical uses of each of the drugs, and examples of drugs in each schedule. To apply for a DEA number, the physician must complete and submit DEA Form 224, Application for Registration (Figure 32-6) either online or by mail. This
certificate is renewable every three years. Each DEA number is site specific so if the physician practices at more than one location, most likely he or she will need a separate DEA number for each location (this may vary when practicing at more than one location in the same area—check with the local DEA office). A physician’s DEA number must be included on any prescription for a controlled substance and should not be used on prescriptions that are noncontrolled substances.
Storage of Controlled Substances Controlled substance labels include a large “C” followed by the Schedule classification (Figure 32-7). All con-
TABLE 32-3 Controlled Substances Schedule SCHEDULE AND CLASSIFICATION LISTING ON LABEL
POTENTIAL FOR ABUSE
ACCEPTED MEDICAL USES
EXAMPLES
Schedule I C-I on label
High potential for abuse; there is a lack of accepted safety for use under medical supervision
Not accepted for medical use within the United States; may be used for research under certain conditions
gamma hydroxybutyrate (GHB), heroin, khat, marijuana, mescaline, peyote
Schedule II C-II on label
High potential for abuse; abuse may lead to severe psychological or physical dependence
Accepted medical use within the United States but with severe restrictions
cocaine, Dilaudid, methadone, morphine, nembutal, oxycodone, percodan, Ritalin
Schedule III C-III on label
Potential for abuse but less than first two schedules; may lead to low to moderate physical dependence, or moderate to high psychological dependence
Accepted medical use within the United States
Codeine with aspirin, Hydrocodone with aspirin, Lorcet, Talbutal, Testosterone, Vicodin
Schedule IV C-IV on label
Low potential for abuse compared to drugs in schedule III; may lead to limited physical or psychological dependence
Accepted medical use within the United States
Buspar, Chloral hydrate, Darvon, diazepam, Librium, Valium, Xanax
Schedule V C-V on label
Low potential for abuse compared to drugs in schedule IV; may lead to limited physical or psychological dependence
Accepted medical use within the United States
Motofen, Kapectolin PG, Robitussin A-C (with Codeine)
Note: Trade names are capitalized; generic names are lowercased. Prescription refill information for drugs in each schedule can be found in Table 32-4.
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FUNDA MENTALS OF PHARM ACOLOGY
AP P R OV E D OMB NO 1117-0014 F OR M DE A-224 ( 10-06 ) P revious editions are obs olete
A P P L IC AT ION F OR R E G IS T R AT ION
F orm-224
Under the C ontrolled S ubs tanc es A c t INS T R UC T IONS
Save time - apply on-line at 1. 2. 3. 4. 5.
www.deadivers ion.us do j .gov
You MUS T be currently authorized to pres cribe, dis tribute, dis pens e, conduct res earch, or otherwis e handle the controlled s ubs tances in the s chedules for which you are applying under the laws of the s tate or juris diction in which you are operating or propos e to operate.
S TAT E L IC E NS E (S ) B e s ure to inc lude both s tate licens e numbers if applicable
DE A OF F IC IAL US E :
S tate Licens e Number ( required)
E xpiration Date ( required)
/
To apply by ma il complete this application. K eep a copy for your records . P rint c learly, us ing black or blue ink, or us e a typewriter. Ma il this form to the addres s provided in S ection 7 or us e enc los ed enve lope. Inc lude the correct payment amount. F E E IS NON-R E F UNDAB LE . If you have any ques tions ca ll 800-882-9539 prior to s ubmitting your application.
S tate C ontrolled S ubs tance Licens e Number (if required)
Do you have other DE A regis tration numbers ? NO
YE S
F E E F OR T HR E E (3) Y E AR S IS $551 F E E IS NON-R E F UNDA B L E
P leas e print ma iling addres s changes to the right of the addres s in this box.
E xpiration Date
/
S E C T ION 5
IMP OR TA NT All ques tions in this s ection mus t be ans wered.
Name 1
Name 2
Individual R egis tration
YE S
NO
YE S
NO
YE S
NO
YE S
NO
1. Has the applicant ever been c onvic ted of a c rime in connection with controlled s ubs tance ( s ) under s tate or federa l law, or is any s uch action pending? Date (s ) of inc ident MM-DD-Y Y Y Y:
A P P L IC A NT IDE NT IF IC AT IION
/
MM - DD - Y Y Y Y
What s tate was this licens e is s ued in?
L IA B IL IT Y
S E C T ION 1
/
MM - DD - Y Y Y Y
What s tate was this licens e is s ued in?
IMP OR TANT: DO NOT S E ND T HIS AP P LIC AT ION A ND AP P LY ON-LINE .
MA IL -TO A DDR E S S
S E C T ION 4
793
2. Has the applicant ever s urrendered ( for caus e ) or had a federal controlled s ubs tance regis tration revoked, s us pended, res tricted, or denied, or is any s uch action pending? Date (s ) of inc ident MM-DD-Y Y Y Y: 3. Has the applicant ever s urrendered ( for caus e ) or had a s tate profes s iona l licens e or controlled s ubs tance regis tration revoked, s us pended, denied, res tricted, or placed on probation, or is any s uch action pending?
B us ines s R egis tration
Date (s ) of inc ident MM-DD-Y Y Y Y:
( Las t Name of individua l -OR - B us ines s or F ac ility Name )
4. If the applicant is a c orporation ( other than a corporation whos e s tock is owned and traded by the public ) , as s oc iation, partners hip, or pharmacy, has any officer, partner, s tockholder, or proprietor been convic ted of a c rime in connection with controlled s ubs tance ( s ) under s tate or federa l law, or ever s urrendered, for caus e, or had a federal controlled s ubs tance regis tration revoked, s us pended, res tricted, denied, or ever had a s tate profes s iona l licens e or controlled s ubs tance regis tration revoked, s us pended, denied, res tricted or placed on probation, or is any s uch action pending?
(F irs t Name and M iddle Name of individua l - OR - C ontinuation of bus ines s name )
Note: If ques tion 4 does not apply to you, be s ure to mark 'NO'. It will s low down proces s ing of your application if you leave it blank.
Date (s ) of inc ident MM-DD-Y Y Y Y:
S treet Addres s L ine 1 ( if applying for fee exemption, this mus t be addres s of the fee exempt ins titution)
E XP L A NAT ION OF " Y E S " A NS WE R S
Liability ques tion #
Location(s ) of inc ident:
Applicants who have Nature of inc ident: ans wered "Y E S " to any of the four ques tions above mus t provide a s tatement to explain eac h " Y E S " ans wer.
Addres s L ine 2
C ity
B us ines s P hone Number
P oint of C ontact
B us ines s F ax Number
E ma il Addres s
Us e this s pace or attach a s eparate s heet and Dis pos ition of inc ident: return with application
Zip C ode
S tate
S E C T ION 6 E XE MP T ION F R OM A P P L IC AT ION F E E C heck this box if the applicant is a federa l, s tate, or loca l government official or ins titution. Does not apply to contractor-operated ins titutions . B us ines s or F ac ility Name of F ee E xempt Ins titution. B e s ure to enter the addres s of this exempt ins titution in S ec tion 1.
DE B T C OL L E C T ION INF OR MAT ION
T he unders igned hereby certifies that the applicant named hereon is a federa l, s tate or loca l government official or ins titution, and is exempt from payment of the application fee.
S oc ial S ecurity Number ( if regis tration is for individual )
Mandatory purs uant to Debt C ollection Improvements Act
F OR P rac titioner or ML P ONLY:
S E C T ION 2 B US INE S S A C T IV IT Y C heck one bus ines s activity box only
P rofes s iona l Degree :
P rofes s iona l S chool :
select from list only
C heck a ll that apply
F E E E XE MP T C E R T IF IE R P rovide the name and phone number of the certify ing official
S E C T ION 7
C entra l F ill P harmacy R eta il P harmacy Nurs ing Home Automated D is pens ing S ys tem
DR UG S C HE DUL E S
Year of G raduation :
N a tiona l P rovide r I de ntific a tion:
F OR Automated D is pens ing S ys tem ( ADS ) ONLY:
S E C T ION 3
Tax Identification Number ( if regis tration is for bus ines s )
P rovide S S N or T IN. S ee additiona l information note #3 on page 4.
S ignature of certifying official ( other than applic ant)
Date
P rint or type na me a nd title of c e rtifying offic ia l
Te le phone N o. ( required for verification)
C heck
Make check payable to: Drug E nforc ement A dminis tration S ee page 4 of ins tructions for important information.
D a te of B irth ( MM-DD-Y Y Y Y ):
ME T HOD OF PAY ME NT
M M
C heck one form of payment only
C redit C ard Number
S ign if pay ing by credit card
S ignature of C ard Holder
D D
P ractitioner ( DDS , DMD, DO, DP M, DV M, MD or P HD )
P ractitioner Military ( DDS , DMD, DO, DP M, DV M,MD or P HD )
Mid-leve l P ractitioner ( MLP ) ( DOM, HMD, MP, ND, NP, OD, PA, or R P H )
E uthanas ia Technician
Y Y
Y Y
Dis c ove r
Mas ter C ard
Ma il this form with payment to:
Vis a
U.S . Department of J us tice Drug E nforcement Adminis tration P.O. B ox 28083 Was hington, DC 20038-8083
E xpiration Date
Ambulance S ervice Anima l S he lter Hos pita l/C linic Teaching Ins titution An ADS is automatica lly fee-exempt. S k ip S ection 6 and S ection 7 on page 2. You mus t attach a notorized affidavit.
DE A R egis tration # of R eta il P harmacy for this ADS
American E xpres s
S chedule II Narcotic
S chedule III Narcotic
S chedule IV
S chedule II Non-Narcotic
S chedule III Non-Narcotic
S chedule V
C heck this box if you require official order forms - for purchas e or trans fer of s chedule 2 narcotic and/or s chedule 2 non-narcotic controlled s ubs tances . NE W - P age 1
F E E IS NON-R E F UNDA B L E
P rinted Name of C ard Holder
S E C T ION 8 A P P L IC A NT 'S S IG NAT UR E
I certify that the foregoing information furnis hed on this application is true and correct. S ignature of applic ant ( s ign in ink )
Date
S ign in ink
P rint or type name and title of applicant WA R NING : S ection 843 ( a ) ( 4 ) ( A ) of T itle 21, United S tates C ode s tates that any pers on who knowingly or intentiona lly furnis hes fa ls e or fraudulent information in the application is s ubject to impris onment for not more than four years , a fine of not more than $30,000, or both. NE W - P age 2
FIGURE 32-6 DEA Form 224 is the form that physicians use to register for a DEA number to prescribe controlled substances.
trolled substances should be kept separate from other drugs and must be stored in a secure cabinet or drawer. Medical facilities that house large amounts of Schedule II drugs or that are located in high crime areas usually have more stringent storage specifications, such as storing the drugs in a floor safe or a steel container affixed to a cabinet or wall (Figure 32-8). Further security measures may include an alarm system, security cameras, and the appointment of a security manager. All prescription pads and order blanks for controlled substances should also be securely locked away. Only a minimal number of staff members (usually the physician and/or supervisor) should have keys to cabinets containing these items. FIGURE 32-7 Notice the Roman numeral beside the C. This indicates that the medication is a controlled drug.
Ordering Requirements of Controlled Substances When a physician orders Schedule II drugs for dispensing or administration purposes, a special triplicate form, DEA Form 222, must be completed and sent to the supplier. These forms may only be ordered by
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45698T
794
FIGURE 32-8 Controlled substances should be double-locked for extra protection.
FIGURE 32-9 Notice the location of the expiration date.
physicians that have a valid DEA number, as the form is preprinted with the registrant’s name and address. One original copy of the form is kept by the office, and the others are sent to the supplier. The supplier keeps one copy of the form and sends the third copy to the nearest DEA office after the shipment has been filled. The DEA recently introduced new technology to enable electronic completion of these forms, though only a small percentage of offices and suppliers are currently set up to use this technology. No special order forms are necessary for Schedule III–V drugs, but the supplier must be able to verify that customers are who they say they are.
should be placed in sealable plastic bags with a little water to assist in dissolving. The bags should be sealed and discarded in regular trash. Liquid substances should be mixed in plastic sealable bags with items such as coffee grounds, cat litter, or absorbent paper towels and sealed closed before discarding in the trash. Drugs should not be flushed down a drain or toilet unless instructions on the label advise to do so. Some offices place expired noncontrolled medications in the biohazardous trash or take them to a pharmaceutical take-back location that disposes of expired medications in an appropriate manner. Before disposing of controlled substances, the registrant (physician) or agent for the registrant (office supervisor) should complete and submit DEA Form 41, Registrants Inventory of Drugs Surrendered, and wait for instructions from the DEA to proceed. The DEA will send the form back with instructions on what to do. Once the office has disposed of the drug per the DEA instructions, the original and two copies of the DEA form should be sent back to the DEA office and a copy should be kept for the office. There are a variety of responses that the DEA may send, such as disposing of the substance in front of two other witnesses, mailing the substance to the DEA office, or having a DEA agent present during the disposal. Disposal records should be kept for a minimum of two years. The practice may use the services of a reverse distributor (a company authorized to accept and destroy all types of expired drugs for a fee) to dispose of these drugs. If a controlled substance spills or breaks in the container in which it is stored and is not recoverable, the registrant must document the incident in the inventory record. When possible, two individuals who witnessed the breakage should sign the inventory records indicating what they witnessed.
Recordkeeping Requirements of Controlled Substances The DEA requires that a full inventory of all controlled substances be completed every two years. Records from that inventory must be kept for a minimum of two years. Daily or shift inventories should be performed in areas in which staff has access, and witnesses should be present. Any time controlled substances are received, dispensed, or administered, they should be recorded in a special log. New shipments should be witnessed by at least two other persons.
Proper Disposal of Both Controlled and Noncontrolled Drugs Drugs should never be used past their expiration date. When the expiration date (Figure 32-9) has been reached, the medications must be removed from the current drug inventory and disposed of in a proper manner. Drugs should always be removed from their original containers prior to disposal to keep others from using them. Solids, such as tablets and capsules,
E M R A P P L I C AT I O N Many EMR programs house medication logs within the EMR software. Individual patients should have a medication log stored within their personal electronic chart. The software may also include a global log that tracks vaccines and narcotics given to the entire patient population.
Global logs provide tracking information that is useful when there is a problem with a particular lot number of medication. These logs can also provide statistical data that identifies the prescribing activities of individual physicians.
Controlled Substances That Are Stolen
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When controlled substances are stolen, notify the local DEA office and police immediately. DEA Form 106, Theft or Loss of Controlled Substances, should be completed by the physician and sent to the DEA. One copy of the form should be kept by the office. Many ambulatory care centers have stopped stocking controlled substances due to the extra work involved in the inventory process. Refer to Procedure 32-1 for a procedure on maintaining medication records.
C R I T I C A L T H I N K I NG CHALLENGE While loading a glass cartridge of Demerol into a Carpujet unit, you drop the cartridge on the floor, breaking it into several pieces. 1. What steps will need to be taken to comply with DEA regulations?
THE MEDICATION ORDER/ PRESCRIPTION WRITING
tions for particular medications. The prescription can be broken down into nine different sections. Figure 32-10 shows an example of a prescription and lists and defines the different parts of a prescription.
The prescription is a written legal document that lists compounding, dispensing, and administering instruc-
FIGURE 32-10 All prescriptions should have a minimum of the nine sections shown here. Parts of a Prescription 1. The physician's name, address, telephone number, and registration number. 2. The patient's name, address, and the date on which the prescription is written. 3. The superscription that includes the symbol Rx ("take thou"). 4. The inscription that states the names and quantities of ingredients to be included in the medication. 5. The subscription that gives directions to the pharmacist for filling the prescription. 6. The signature (Sig) that gives the directions for the patient. 7. The physician's signature blanks. Where signed, indicates if a generic substitute is allowed or if the medication is to be dispensed as written. 8. REPETATUR 0 1 2 3 PRN. This is where the physician indicates whether or not the prescription can be refilled. 9. LABEL. Direction to the pharmacist to label the medication appropriately.
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TOOL BOX
FUNDA MENTALS OF PHARM ACOLOGY
L&K
Name Address
LEWIS & KING 2501 CENTER STREET NORTHBOROUGH, OH 12345
Juanita Hansen 143 Gregory Lane, Apt. 43
Date
4/7/XX
Furadantin 50 mg Tabs #56 Sig 1 tab p.o. q.i.d X14 days Generic Substitution Allowed
Susan Rice
M.D.
Dispense As Written REPETATUR 0 1 2 3 PRN LABEL
M.D.
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Written prescriptions must either be written in permanent ink or indelible lead. Prescriptions may be given directly to the patient, faxed to the pharmacy, called into the pharmacy, or may be sent to the pharmacy in digital format. All prescriptions must be signed by the physician. Electronic prescriptions must include the physician’s digital signature to verify that the prescription is authentic. The role of the medical assistant regarding prescription tasks will vary according to state law and office policy, but may include: ❖ Writing prescriptions under the direction of the physician for medications that are nonscheduled or that are listed in Schedules III–V ❖ Calling in prescriptions to pharmacies under the direction of the physician for medications that are nonscheduled or listed in Schedules III–V ❖ Faxing prescriptions under the direction of the physician to the pharmacy ❖ Providing patients with instruction on how to properly take their medications and what side effects to look for Even when the medical assistant writes the prescription, the physician must sign the prescription in order for it to be valid.
Prescription Abbreviations The use of standard medical abbreviations is greatly discouraged when performing any type of clinical doc-
umentation, whether it is written, printed, or in electronic format. A vast number of injuries and deaths have been associated with the use of abbreviations. As a result, some health care organizations are banning the use of all abbreviations in regards to clinical documentation, while other organizations are only banning abbreviations that are considered dangerous. The Joint Commission’s 2004 “Do Not Use” list of abbreviations was part of a larger initiative, National Patient Safety Goals, designed to keep patients safe. This list features several abbreviations that are considered dangerous and are not permitted when performing clinical documentation in organizations accredited by the Joint Commission, such as hospitals, clinics, and skilled nursing centers. Many other health care accrediting organizations are instituting the “Do Not Use” list as part of their standards as well. Appendix A provides a listing of common abbreviations that are still used in many medical organizations. Refer to Appendix B for a complete list of “Error-Prone Abbreviations” from the Institute for Safe Medication Practices (ISMP) that features all of the Joint Commission’s “Do Not Use” abbreviations as well as suggestions for the discontinuance of other abbreviations. Keep in mind that the “Error-Prone Abbreviations” list can expand at any time and the medical assistant is responsible for keeping up to date with any changes. Procedure 32-2 lists steps for writing a prescription. Information for documenting prescriptions within the patient’s chart can be found in Chapter 4.
Patients should receive the following instructions regarding prescription medications: ❖ Take medication as directed by the physician. ❖ Take all of the medication for the length of time prescribed. ❖ Do not stop taking the medications without consulting the physician first. ❖ Inform the physician of any unusual or adverse effects from taking the medications. ❖ Do not combine OTC medications or herbal supplements without notifying the physician.
❖ Do not take someone else’s medication or give the medication to someone else. ❖ Store all medications away from children. ❖ Discard unused medications. ❖ Follow all warning labels on the medication container. ❖ Check the medication storage area at home regularly for expired or unused drugs and dispose of them by flushing them down the toilet. (Make certain drugs are environmentally safe before disposing of them down the toilet.)
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PAT I E N T T U T O R
FUNDA MENTALS OF PHARM ACOLOGY
Rules for Writing or Calling in Prescriptions for Controlled Substances Medical assistants must be familiar with rules and guidelines associated with their particular state and office when it comes to writing or calling in prescriptions for controlled substances. Information that should be included when writing or calling in prescriptions for controlled substances is similar to those for noncontrolled substances but with a few inclusions. Table 32-4 lists rules for prescriptions for controlled substances.
Tamper-Resistant Prescription Pads Many states, such as California, now require prescrptions for controlled substances to be written on spe-
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797
cialized tamper-resistant prescription pads. Examples of required-tamper resistant features in the state of California include: The prescription paper must be both heat and chemically sensitive, the paper must have anti-copy features that cause the word “void” to appear if someone tries to make a copy of the prescription, the opaque Rx symbol must disappear if someone tries to lighten the form, and a warning band describing the form’s security features must be printed on the prescription. California also requires a statement, “Prescription is void if the number of drugs prescribed is not noted,” with a line allowing physicians to write in the number. These prescription pads can only be ordered from state-approved vendors that use security printers to create the pads. Other states also require
TABLE 32-4 Rules for Prescriptions for Controlled Substances All controlled substances
The form must include the physician’s DEA number The amount must be written out (six rather than 6) or combined [six (6)]. The amount prescribed is usually limited to smaller quantities than noncontrolled substances. Many states require controlled substance orders to be written on a special security tamper-resistant prescription pad.
Schedule II
Except in emergencies, drugs in this schedule must be both handwritten and signed by the physician in permanent ink (many states also require prescription orders to be written on a special tamper-resistant pad). The physician may call in an order for schedule II drugs for emergency purposes, but only for the amount of the drugs necessary to get through the emergency. The pharmacy must receive a written prescription within seven days following a phone order from this schedule. Some states require the diagnosis to appear on the prescription for certain categories of drugs within this schedule. Currently, no refills are permissible in any state; however, some states allow physicians to write one prescription for a 60- or 90-day supply under special circumstances. Medical assistants may not write a prescription or call in a prescription for drugs in this schedule under any circumstance.
Schedules III–V
Orders may be handwritten, typed, given over the phone, or faxed to the pharmacy. The required use of tamper-resistant prescription pads varies according to state and federal guidelines. May be refilled up to five times within a six-month period. There may be some variances with Schedule V drugs depending on the state. Some Schedule V drugs can be dispensed by a pharmacy without a prescription. Orders may be written in 30-, 60-, or 90-day increments. Many states will allow the medical assistant to call in these drugs, but the state’s pharmacy statutes should be checked.
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tamper-resistant pads, but most states do not require all of the features that California requires.
DRUG RESOURCES There are a number of resources and reference books (Figure 32-11) available that provide helpful information about particular drugs. These resources and reference books are updated periodically to provide the most current drug listings and information. Common resources include the Physician’s Desk Reference, the U.S. Pharmacopecia/National Formulary, drug package inserts, nursing drug books, and drug-related Web sites.
The Physician’s Desk Reference The Physician’s Desk Reference (PDR) is published every year by Thomson Medical Economics. This reference is one of the most popular drug reference guides and is commonly found in physicians’ offices, hospitals, and specialty clinics. The PDR is divided into color-coded sections. Table 32-5 lists each of those sections and includes a description of each. There are many additional lists, charts, and forms throughout the PDR, including a listing of FDA drug information centers, a key to controlled substances categories, a key to use-in pregnancy ratings, dosing instructions in Spanish, the ISMP’s list of error-prone abbreviations symbols, dose designations, and several reporting forms.
FIGURE 32-11 The PDR and other drug reference guides
U.S. Pharmacopecia/National Formulary
SAFE DRUG ADMINISTRATION
The U.S. Pharmacopecia/National Formulary (USP/NF) is considered the official book of drug standards. It contains standards for all medications, dietary supplements, and medical devices. It also contains a national formulary of all drugs that have been approved for use in the United States. The USP/NF is published every five years and includes drugs that have been tested and certified that meet specific standards of quality, purity, and potency. It is used most often by pharmaceutical companies, research laboratories, and companies that manufacture medical devices. It is occasionally used by providers.
Medication preparation and administration should take place in a well-lit area. The medical assistant should
Drug Product Package Inserts Drug product inserts are included in every packaged medication. This insert describes all significant aspects of the drug, such as the chemical name, generic name, recommended dosage, and dosage intervals. The information provided may also include findings of clinical studies and possible side effects of the drug throughout the drug studies.
Drug Resources on the Internet Many health care professionals have come to rely on the Internet for reviewing drug listings and finding the most current drug information available. Pharmaceutical company Web sites provide product information, and a variety of other Web sites developed for health advocacy have wonderful resources as well. Several Web sites that can be used to gather drug information are listed at the end of this chapter.
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C R I T I C A L T H I N K I NG CHALLENGE A busy physician leaves an order for you to write prescriptions for two separate patients. One of the patients needs a prescription for Valium and the other patient needs a prescription for Percodan. Using a drug reference book, check to see which schedule these drugs fall under. 1. Is the medical assistant able to write prescriptions for these two drugs? 2. If not, explain why. Does a special prescription pad need to be used for either of these prescriptions?
FUNDA MENTALS OF PHARM ACOLOGY
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TABLE 32-5 PDR Sections
SECTION
PAGE COLOR
1
SECTION TITLE
CONTENT DESCRIPTION
Gray
Manufacturer’s Index
This section lists pharmaceutical manufacturers in alphabetical order along with the name and address of each manufacturer. A list of drugs supplied by each manufacturer and page numbers that elaborate on each drug are also included in this section.
2
White
Brand and Generic Name Index
This section lists drugs in alphabetical order by both generic and brand name, followed by two sets of page numbers. The first number indicates the page on which a picture of the drug can be found, and the second number indicates the page on which product information can be found. This is a great starting place when looking up drug information.
3
Gray
Product Category Index
This section divides drugs alphabetically into categories by classification. This section gives the reader an opportunity to compare similar drugs made by different manufacturers.
4
Gray
Product Identification Guide
This section provides full color (actual size) photographs of the tablets and capsules of those included in the PDR and is arranged alphabetically by manufacturer. This section can be used when the patient knows what the pill looks like but doesn’t know the name of the drug.
5
White
Product Information
This is the main section of the book. It includes product information arranged alphabetically by manufacturer. The information in this section comes directly from the package insert and includes the following information about the drug: description, clinical pharmacology, indications, contraindications, warnings, precautions, adverse reactions, dosage and administration, and how the drug is supplied.
6
White
Diagnostic Product Information
This section is listed alphabetically by manufacturer and provides guidelines for a variety of diagnostic agents.
avoid becoming distracted while preparing medications to reduce the risks of medication errors. Drugs should always be checked to make certain that they have not yet reached their expiration date and that they have been stored correctly to ensure drug effectiveness. Many drugs can be stored at room temperature; however, some drugs must be stored in a refrigerator or freezer.
Seven Rights of Drug Administration The medical assistant should have a complete understanding regarding a drug’s use, dosage, how it is to be given, and common side effects. Patient safety is
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FI E L D S M A R T S Thermometers should be used to make certain that refrigerators housing medications are at the correct temperature. A drop in temperature can ruin an entire batch of medication. Always make certain that the door to the medication refrigerator is closed and sealed tightly after use. Refrigerators that store drugs should be backed up with a generator.
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S I T E C H EC K As a site surveyor, I will check to make certain that the practice is tracking temperatures of refrigerators used to stock medications. If any deficient temperatures appear in the log, a description of what was done with the medications that were in the refrigerator at the time of discovery should be logged as well.
further promoted by following the Seven Rights of Drug Administration: 1. The Right Patient: Verify the patient’s name with the chart and confirm it is the right patient by using another identifier such as the patient’s date of birth or last four digits of the patient’s social security number (the National Patient Safety Goals requires the use of two identifiers). 2. The Right Drug: Check the label a minimum of three times to confirm that it is the right drug and the right strength by comparing the physician’s written order against the drug label. Read the drug label when: • Removing the medication from the storage area • Preparing the medication • Placing the medication back into the storage area or before discarding the used container FIGURE 32-12 A medication entry within a progress note
3. The Right Dose: If necessary, perform the proper calculations to determine the correct dosage to be given. Refer to Chapter 33 for examples of dosage calculations. 4. The Right Route: Check the drug order to ensure that the route of administration is the correct route for the drug being given and for the patient receiving the drug. 5. The Right Time: This is usually not a factor in ambulatory health centers because drugs are normally administered at the time they are ordered, but always read the order for clarification. 6. The Right Technique: Learning the procedures for proper drug administration will assist the medical assistant in knowing how to administer the medications. When in doubt, check the drug insert or ask the physician for clarification. 7. The Right Documentation: Giving the medication is only half of the procedure; the other half is documenting the procedure. Most likely the medication will need to be documented in a variety of locations, such as the patient’s progress note, a special medication log in the patient’s chart, a global vaccine or narcotics log for the practice, and possibly a personal log for the patient. Refer to Chapter 4 for information that must be documented in medication entries. Figure 32-12 shows an example of a medication entry within a progress note. Always have the patient wait 20 to 30 minutes following drug administration. This is the usual time
Progress Note For:
DOUGLASVILLE MEDICINE ASSOCIATES
Jessica Hunnicutt
5076 BRAND BLVD, DOUGLASVILLE, NY 01234
12-12-1985
(123) 456-7890
03-06-XX
Adult Td vaccine, 0.5 mL, IM, left deltoid per Dr. Smith.
3:15 p.m.
Manf: Lilly, Lot # FR244336, Exp. date: 09-05-XX. Pt. tolerated well. VIS reviewed and consent signed and filed in chart. Pt. education given. Pt. appeared to understand the instructions. Had pt. wait for 20 minutes following administration. No signs of anaphylaxis or local reactions. Dismissed pt @ 3:35. Amanda Wolfe RMA
FUNDA MENTALS OF PHARM ACOLOGY
period in which anaphylactic reactions occur. Signs of anaphylaxis and treatment steps for treating anaphylaxis can be found in Chapter 35.
Safety and Continuity during Medication Administration “PAD” is an acronym that can be used during the drug administration process. It stands for “Preparation, Administration, and Documentation,” which is the chain of events that should be performed by only one person during medication administration. Errors during any step of the process can lead to serious consequences for the patient. ❖ Preparation: Never allow another person to prepare a medication that you are going to administer. You cannot guarantee that the medication was prepared properly. ❖ Administration: Never allow another person to administer a medication that you prepare. If an error occurs during administration, you may be held accountable should an adverse event occur. ❖ Documentation: Following preparation and administration, you need to make certain that documentation is correct and complete. Never have someone else document for you. Remember the adage, “If you didn’t document it, you didn’t do it!”
Reporting Medication Errors Medication errors can occur at any time and the medical assistant must know how to respond in the event an error should occur. It is important to understand the reasons why the medication error occurred and to thoroughly evaluate the incident to ensure that the error is not repeated. Some of the most common reasons medication errors occur are:
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❖ Not reading the label carefully ❖ Confusing a drug with another that is spelled almost the same or sounds almost the same ❖ Not calculating the dosage correctly ❖ Trying to multitask while preparing a medication If a medication error occurs, there are specific steps that must be followed: ❖ Recognize that an error has occurred: Never try to conceal a drug error. It could be fatal for a patient. ❖ Remain calm: Panic may delay the appropriate treatment. ❖ Notify the physician stat: Calmly and discretely provide the necessary details. ❖ Assess the patient for any reaction to the medication: Review the patient’s vital signs and look for any other signs of distress. ❖ Respond appropriately to the physician’s orders. ❖ Document the error in the patient’s medical chart and complete an incident report.
ROUTES OF MEDICATION ADMINISTRATION There are two major routes by which drugs can be administered: enteral and parenteral. The term enteral means pertaining to the alimentary canal or intestines. Medications that pass through any structures within the alimentary canal may be considered enteral medications and include the following specific routes: oral, buccal, sublingual, and rectal. (Buccal, rectal, and sublingual routes may also be considered submucosal routes because they pass through a mucus membrane within the alimentary canal to get into the bloodstream.) Nasogastric tubes and gastric tubes may be used to deliver enteral medications in patients unable to take medications orally.
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CR ITI C A L TH I N K I N G C H AL LEN G E
FI E L D S M A R T S
You are running behind schedule and Sarah, another medical assistant, offers to help you by preparing some of the medications you are to administer to another patient. 1. Is this acceptable? If not, why? 2. What would be a good response to give to Sarah?
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The latest National Patient Safety Goals state that drugs that look-alike/sound-alike (LASA) should be stored separately from one another. Drug alert stickers can be purchased to place on shelves that store LASA products. Health care personnel may also consider highlighting the part of the drug that is different, such as hydr-OXY-zine and hydr-ALA-zine.
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Parenteral means pertaining to beside or outside of the intestines. Parenteral medications include any drugs delivered by a method other than through the digestive tract, including topical, transdermal, mucosal, inhalation, injectable, and intravenous. The most common parenteral medications are injectables. See Chapter 34 for procedures relating to administering injections and intravenous medications. The route that is used to deliver the medication is determined by several factors, including the manufacturer’s recommendations, the physician’s preference, and special requests from the patient. Some drugs can only be given through one route due to the chemical
composition of the drug or because the drug can be caustic or toxic when given through other routes.
Enteral Routes Again, enteral medications pertain to medications that pass through any organs of digestion. Enteral routes used in ambulatory care are usually limited to the oral and rectal routes.
Oral Medications Oral medications come in a variety of different forms and should only be given to conscious patients who can swallow without difficulty. Table 32-6 lists infor-
TABLE 32-6 Solid Oral Medications TYPE
EXPLANATION
Tablets
A medication that is usually mixed with a special binding powder and pressed and molded into a particular shape, most often a round disc. Most tablets are designed to be absorbed high in the gastrointestinal tract but may be enteric coated, designed to break down and be absorbed in the intestines. Some tablets are buffered to help decrease acidity in the stomach. Coated tablets should never be altered by smashing into a powder and mixing with a liquid because it prevents the drug from being absorbed properly. Tablets may be scored (lined) for cutting in half.
Caplet
A smooth, oval, coated tablet designed for easier swallowing.
Capsules
A dose of oral medication housed in a special soluble container, usually gelatin. Capsules usually dissolve in the stomach but may be enteric coated (designed to dissolve in the intestines). May be sustained release (SR) or time released, meaning that the different granules within the capsule are designed to be released at different times.
Gel caps
An oil-based medication that is encased in a gelatin shell.
Lozenge or troche
Medication that is encased in round or oval candy coating. Designed to be dissolved in the mouth and assists with soothing irritated tissue of the throat.
FUNDA MENTALS OF PHARM ACOLOGY
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FIGURE 32-13 The proper placement for buccal medications
FIGURE 32-14 The proper placement for sublingual medications
mation regarding oral medications that are in solid forms. Oral medications commonly travel through the digestive tract, where they are digested and absorbed in the stomach or intestines. Other medications are taken into the oral cavity but do not travel through the digestive tract. Buccal medications are placed between the gums of the upper molars and the inside cheek (Figure 32-13) where they are rapidly absorbed through vasculature within the mucus membranes. Sublingual medications are placed under the tongue (Figure 32-14) and also provide rapid absorption into the bloodstream. Nitroglycerine is an example of a drug that is given sublingually. Buccal and sublingual medications should not be swallowed and medications that are meant for absorption in the intestines should not be given bucally or sublingually.
Liquid medications for pediatric patients are frequently packaged with a medicine cup (Figure 32-15), oral syringe, medicine spoon (Figure 32-16), or a calibrated medicine dropper (Figure 32-17). Patients should not be allowed to consume any liquids after drinking a liquid medication until confirming with instructions on the medication label. Refer to Procedure 32-3 for steps on how to administer oral and liquid medications.
Liquid Medications Liquids are often used as a vehicle to deliver medication (Table 32-7). Whenever possible, children should be given liquids until they can safely swallow pills. Adults that have great difficulty swallowing pills may also be offered liquids. The medical assistant should read the entire label for clarification.
Administering Medications through Feeding Tubes Some enteral medications may be delivered through a patient’s feeding tube. Medical assistants do not typically administer drugs using this route. Patients who have neuromuscular disorders, are unconscious, or are in a vegetative state are often fed through a feeding tube. A feeding tube may extend from the nasal cavity into the stomach or intestines, or may be directly attached to the stomach or intestines through an opening in the skin.
Rectal Medications Rectal medications are often given to patients who cannot keep medication down due to gastrointestinal
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TABLE 32-7 Types of Liquid Medications TYPE
EXAMPLES
DESCRIPTION
Syrups
Cough syrup
A concentration of medicine mixed with sugar water. Used as a vehicle to transport distasteful medications.
Extracts
Allergy extracts
A highly concentrated form of medicine made by mixing the leaves of a plant with alcohol. The solid matter is removed (extracted), leaving just the plant oils mixed with alcohol. This produces a much more concentrated form of the drug than its original form.
Elixirs
Cough or cold medications
A medication sustained in a sweetened liquid usually containing alcohol. It may be used for its flavoring or medicinal properties.
Tinctures
St. John’s wort, tincture of iodine
A chemical or soluble drug prepared in an alcoholic solvent
Magmas
Milk of magnesia
Minerals suspended in water. These should be well mixed before use.
Suspension
Ear and eye medications (such as Zithromax)
Medication particles that are dissolved in a liquid. Must be mixed well before administering.
Sprays
Throat and nasal sprays
Sprays may be used to anesthetize the back of the throat to relieve pain. Some nasal sprays are delivered into the nasal mucosa for relief of allergy symptoms.
Washes
Oral rinses
Frequently used for oral health. These are rinses that are gargled and spit back out.
FIGURE 32-15 A medication cup with measurement markings
FIGURE 32-16 Oral syringes and medication spoons are great
for proper dosage
for administering liquids to young children.
2 tbs
30 cc
3 0 ml 25 ml
1 fl oz
8 fluidrams
3/4 fl oz
6 fluidrams
15 cc
20 ml 15 ml
1/2 fl oz
4 fluidrams
10 cc
10 ml
1/4 fl oz
2 fluidrams
1/8 fl oz
1 fluidram
25 cc
20 cc
1 tbs 2 tsp 1 tsp 1/2 tsp
5 cc
5 ml
FIGURE 32-17 Droppers are good for instilling eye or ear drops and for administering oral medications to infants.
FUNDA MENTALS OF PHARM ACOLOGY
disturbances, are unconscious, or have problems with swallowing. This method of drug absorption minimizes the changes or alterations of drugs that, if given orally, may lose their effectiveness due to gastrointestinal secretions. Rectal medications such as suppositories are often coated with gelatin or cocoa butter (Figure 32-18), which easily melts due to the warm temperatures within the cavity. This promotes rapid absorption of the medication through the vasculature located within the rectal mucosa. These medications are often used to soften the stool, stimulate bowel movements, or relieve nausea and vomiting when the stomach is especially irritated. Suppositories should be kept in a cool area and not directly exposed to heat or sunlight, as this may cause the medication to melt prematurely. The patient should be instructed to remove the foil wrapper or packaging from the suppository and gently insert the suppository past the internal sphincter along the rectal wall. Refer to Procedure 32-6 for a procedure on administering suppositories. An enema (Figure 32-19) is a procedure that may be used to evacuate the bowel before a suppository is inserted or for better viewing prior to rectal exams (see Chapter 14).
Parenteral Medications Parenteral medications are any medications administered outside of the gastrointestinal tract. Advantages of medications delivered via this route include rapid absorption (resulting in a faster response time) and absence of the common side effects often associated with medication taken through the gastrointestinal tract. Disadvantages include rapid onset of allergy symptoms or anaphylaxis and possible injuries to soft
FIGURE 32-18 Rectal suppositories are often coated with gelatin or cocoa butter to assist with absorption.
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FIGURE 32-19 Enemas are often used to assist in bowel evacuation.
tissue or bone tissue during the injection process. Chapter 34 expands on injections and infusion therapy, while other parenteral routes are described in this chapter.
Mucosal Membrane Medications The mucous membranes can be used for administering particular types of medications to produce a systemic effect. Mucous membranes used within the alimentary canal to deliver medications include those membranes used for buccal, sublingual, and rectal medications. Other parts of the body in which mucous membranes are used include: ❖ Ophthalmic membranes: Medications can be delivered within the upper or lower conjunctival sacs of the eye. These medications may be in drop or ointment form and are usually used to treat eye infections or irritation. Chapter 13 includes a procedure for instilling eye ointments and drops. ❖ Otic membranes: Medications can be delivered into membranes within the ear to treat ear infections or to soften cerumen (earwax) for irrigation purposes. Chapter 13 includes a procedure for instilling ear drops. ❖ Nasal membranes: Medications can be administered through mucus membranes of the nose. These medications may help to relieve rhinitis or to relieve nasal congestion. They may be local
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or systemic, and may be in the form of drops or sprays. Inhalation therapy may be delivered through oral or nasal passages in the form of an aerosol or liquid that is vaporized with warm steam or administered by a metered dose inhaler. Medications that are inhaled can produce a local effect by opening air passages within the cavity or a systemic effect by supplying medication to the lungs to be absorbed into the bloodstream. Examples of inhalation drugs include bronchodilators, mucolytic agents, and steroids. Chapter 16 includes a procedure for administering nebulizer treatments and provides tips for using an inhaler. ❖ Vaginal membranes: Medications administered vaginally include sprays, tablets, suppositories, creams, and foams. Hormone creams, contraceptives, and antifungal creams are all examples of the types of medications delivered by this route. Creams are usually administered using an applicator. Patients should be instructed to wear a pad following the administration of vaginal medications to prevent drainage onto the patient’s underwear.
❖ Liniment: A medical preparation that is rubbed into the skin. It is usually mixed with a quick drying solvent such as alcohol or acetone. Aromatic chemical compounds are often included to create a pleasant scent. Liniments are often applied to the skin for the relief of stiff joints and pain and may be applied during therapeutic or relaxation massages. ❖ Ointments: These medications are usually oilbased and used for a variety of purposes. Examples include Vicks Vaporub ointment, which is used to help relieve chest congestion, and burn ointments, which are used to stimulate healing and to stop the pain. Refer to Procedure 32-4 for a procedure on applying topical medications.
Transdermal Patches Transdermal patches (Figure 32-20) are adhesive patches applied to the skin that are impregnated with medication for slow release into the bloodstream. The
Topical Applications Topical agents are medications applied to the skin. They generally provide a localized action. Such medication forms include:
FIGURE 32-20 Nitro-Dur is an example of a transdermal patch that delivers nitroglycerine into the bloodstream. (Courtesy of Novartis.)
F IELD SM A RTS Any time you apply a topical product to the patient’s skin for medicinal purposes, you should wear gloves to avoid penetration of the product into your skin and to avoid possible disease transmission whenever there is a risk of infection. A new disposable spatula or tongue blade may be used when removing these
products from their original containers and an applicator such as a tongue blade or cotton-tip applicator should be used when applying liniments or ointments to the skin. Sterile products and supplies should be used when applying topical products to a wound site.
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❖ Lotion: A medication that comes in liquid form and is applied externally to the skin. Lotions are often used as a topical cleanser to stop pruritis (itching) or to help relieve pain. Lotions may be applied using a soft cloth, cotton ball, or gauze squares and are typically rubbed into the skin. Gold Bond medicated lotion is an example.
FUNDA MENTALS OF PHARM ACOLOGY
Backing layer Drug reservoir Microporous rate-limiting membrane Adhesive formulation Skin surface
Blood vessel
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different layers within the patch (Figure 32-21) allow the medicine to be released at varying time intervals. The date and time that the patch was applied should be written on the patch so that the patient knows when it needs to be changed. The medical assistant should always wear gloves when applying these patches to avoid penetration of the medication into the medical assistant’s skin. Examples of transdermal medications include nicotine patches for smoking cessation, estrogen patches for hormone replacement therapy, morphine patches for management of chronic and debilitating pain, and nitroglycerin for treatment of angina or chest pain. Refer to Procedure 32-5 for a procedure on applying transdermal patches.
FIGURE 32-21 The Nitro-Dur patch is a multilayered unit. It consists of a blocking layer, a reservoir of nitroglycerin, a rate controlling membrane, and an adhesive layer that has a priming dose of nitroglycerine. (Courtesy of Novartis.)
PROCEDURE 32-1 Maintain Medication and Immunization Records Objective: To properly document medications in the patient’s chart and the appropriate logs.
Equipment/Supplies: ❖ Chart with medication order ❖ Label information from the medication container (manufacturer’s name, lot number, expiration date) ❖ Appropriate log (immunization, controlled substances, or basic medication log)
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❖ Any signed authorization forms such as a vaccination information sheet ❖ Writing instrument
PROCEDURAL STEPS
RATIONALE
1. Wash your hands following the medication procedure and before handling the chart.
Hands should be cleansed to avoid contamination of charts and other logs.
2. Assemble the chart, logs, medication label information, and writing instrument.
You will need all of these resources for complete documentation.
3. Record the medication procedure on the progress note within the chart. Document date and time of administration, name of drug, form of drug, amount or dosage given, location (if applicable), route, ordering physician, and medical assistant signature. (Some offices will want the manufacturer’s name, lot number, and expiration date as well.)
Thorough documentation demonstrates that the procedure was performed and notes how it was performed for future reference.
continues
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continued
PROCEDURAL STEPS
RATIONALE
4. Document post check of the injection site and the patient in the progress note following a 20 to 30 minute wait.
This is the time frame that most allergic reactions will occur following parenteral administration of a drug.
5. File any vaccination informed consent forms in the chart.
To illustrate that the patient understood any risks associated with the medication and the purpose of the medication.
6. Record the required information in the appropriate log within the chart if applicable.
Some charts have special logs for vaccines and controlled substances.
7. Record information in the universal log if applicable.
Many offices keep global logs for specific types of medications such as vaccines and controlled substances. This is for tracking purposes.
8. Put the chart and logs in their proper storage place.
DOCUMENTATION EXAMPLE: PROGRESS NOTE
04-16-XX 3:00 p.m. 04-16-XX 3:25 p.m.
Adult Hepatitis B Vaccine, 0.5 mL, IM, R. Deltoid, per Dr. Debrowski. Pt. tolerated procedure well. VIS form read and consent form signed, and placed in chart. Pt. instructed to wait for 20 minutes for post follow-up check. Roger Wong, RMA Post Check: –erythema, rash or edema at injection site. Pt. denies any respiratory difficulties or other unusual sx. Pt. encouraged to call with any questions. Roger Wong, RMA
HEPATITIS B IMMUNIZATION LOG TODAY’S DATE
PATIENT’S NAME
ORDERING PHYSICIAN
04-16-XX Conrad Bently Dr. Debrowski
AMT GIVEN
MANUFACTURER’S NAME
LOT NUMBER
EXP. DATE
0.5 mL
ABC Pharmaceuticals
2145A4
02-15-XX
MA
R. Wong RMA
PROCEDURE 32-2 Write a Prescription Objective: To correctly write a prescription onto a paper prescription blank.
Equipment/Supplies: ❖ Medication order from physician ❖ Patient’s chart
❖ Prescription blank ❖ Writing instrument
PROCEDURAL STEPS
RATIONALE
1. Assemble the chart, order for medication, and prescription pad.
You will need all of these resources to write the prescription.
FUNDA MENTALS OF PHARM ACOLOGY
RATIONALE
PROCEDURAL STEPS 2. Read the order and ask any questions if you do not understand the order.
Guessing what the physician wants could result in serious complications or even death to the patient.
3. Write in the patient’s name, address, and age or date of birth.
The pharmacy will need this information to process the prescription.
4. If not already on the form, write the superscription, or Rx symbol.
This symbol is usually preprinted on the prescription form.
5. Fill in the information included in the inscription (name of the drug, form of the drug, and strength of the medication).
Being specific will help to prevent potential errors.
6. Fill in the information that should be included in the subscription. This usually refers to the dispense amount. (The dispense amount should include the number itself followed by the written amount in parentheses.)
Writing the amount both numerically and in writing helps to prevent someone from changing the amount later.
7. Fill in the information included in the signature (instructions for taking).
These are special instructions that allow the patient to know how to take the medication and how often.
8. If applicable, check the box that states: Do Not Substitute or Dispense As Written.
If the physician does not want the pharmacist to change to a cheaper generic drug, this box should be checked.
9. Circle the amount of refills.
If refills are ordered, it needs to be documented.
10. Insert the DEA number if applicable.
This is only to be included if the medication is a scheduled drug. It is a requirement if the drug is scheduled.
11. Give the prescription to the physician to read and sign.
All prescriptions must be signed by the physician in order to be legal.
12. Document the order in the patient’s chart.
Illustrates that the prescription was written and what was included in the order.
DOCUMENTATION EXAMPLE: DOUGLASVILLE MEDICINE ASSOCIATES 5076 BRAND BLVD DOUGLASVILLE, NY 01234 (123) 456-7890
Sydney Heller Address: 1234 Hickory Hills, Polaris, NY, 01298
02-04-XX Date: 12-14-XX
Patient’s Name:
DOB:
Amoxicillin Capsules, 250 mg Dispense: # 90 (Ninet y) Sig: 1 cap. PO tid x 10 days X
_____ Dispense as Written Signature:
_____ Do Not Substitute
Trent Valentine, M.D.
DEA # _____________________________________
Number of Refills:
0
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PROCEDURE 32-3 Administer an Oral Medication Objective: To properly administer an oral medication to a patient as ordered by the physician.
Equipment/Supplies: ❖ Written medication order ❖ Proper medication ❖ Plastic medication cup
❖ Medication transport tray ❖ Water ❖ Gloves (optional)
PROCEDURAL STEPS
RATIONALE
1. Working in a well-lit area, verify the physician’s order. Be certain to institute the Seven Rights of Drug Administration.
Understanding the physician’s order and following the seven rights will help to prevent potential errors.
2. Wash your hands and apply gloves (gloves are optional). Assemble the medication and supplies. Check the label on the medication bottle as you retrieve it from the cabinet (Medication check #1).
Washing hands and gloving helps to reduce the number of microorganisms on your hands and protects you from becoming contaminated when retrieving the cup and medication container back from the patient. Checking the label helps to confirm that you have the correct medication.
3. Compare the written drug order with the drug label before preparing the drug. Make certain that you have the right drug and the right dose (Medication check #2). Perform dosage calculation if necessary.
Checking the drug once again helps to verify that you have the correct drug.
4. Check the expiration date of the drug.
Outdated drugs may be altered or have deteriorated in their effectiveness and should not be used.
5. Loosen the lid and remove it from the bottle. Place the lid on the counter so that the inside of the lid is pointing upward. Pour the correct amount of pills into the cap of the medication vial without contaminating the inside of the cap, and then into the medicine cup. (When measuring a liquid form of medication, palm the label before pouring and hold the medication cup at eye level, as in Figure 32-22. Read the volume at the lowest point of the curve in the liquid, or at the meniscus.)
Placing the lid in a downward position onto a counter surface will contaminate the inside of the lid. Pouring the pills into the cap first allows you to pour any extra pills that fell into FIGURE 32-22 Pour the the lid during pouring liquid medication so that it right back into the pill is at eye level. bottle, keeping them as clean or sterile as possible. Palming the label of a liquid medication prevents the label from becoming damaged in the event that the liquid runs onto the label.
6. Replace the medication in its proper storage area. Read the label once again before returning it to verify that it is the correct drug and dosage (Medication check #3).
Checking the drug against the order three times before administering will ascertain that you have the correct drug and correct dose.
FUNDA MENTALS OF PHARM ACOLOGY
PROCEDURAL STEPS
❖
RATIONALE
7. Properly transport the medication to the patient. Be careful not to touch the medication or the inside of the container.
Touching the inner part of the medicine cup will contaminate the container holding the medication, thus contaminating the medication.
8. Identify the patient, using a minimum of two identifiers.
Patient verification is important before administering any drugs to prevent error in administering the wrong drug to the wrong patient. This also complies with the Joint Commission rules for patient safety.
9. Identify yourself, and explain the procedure to the patient.
Explaining to the patient what drugs the patient is taking and why will encourage compliance.
10. Give the patient the medication (Figure 32-23) to swallow and observe the patient to make sure there is no difficulty in taking the medication. With a pill, allow the patient to have plenty of water to ensure the medication has passed from the esophagus into the stomach. Do not give the patient water when giving a liquid medication unless you have confirmed with the package insert and the physician that it is okay to do so.
Drinking water after a liquid medicine can dilute the medication, minimizing its effects.
FIGURE 32-23 Personally hand oral medications to the patient. Watch to make certain the patient takes the entire dose.
11. Properly dispose of the medication cup and other disposable equipment into the garbage and remove gloves and wash hands. 12. Provide the patient with any relevant educational materials and ask the patient to repeat back any instructions to confirm that the patient comprehends the information.
Education is important to encourage patient compliance.
13. Document the procedure in the patient’s chart.
Documentation proves that the procedure was performed.
DOCUMENTATION EXAMPLE:
07-12-XX 10:15 a.m.
Tylenol, 500 mg po per Dr. Legg. Observed pt. swallow med. Gave pt. both verbal and written home care instructions for taking medication at home. Jane Barnes, CMA (AAMA)
PROCEDURE 32-4 Administer a Topical Medication Objective: To properly administer a topical medication to the patient as prescribed by the physician.
Equipment/Supplies: ❖ Written order ❖ Proper medication ❖ Sterile cotton-tip applicator/sterile tongue depressor
❖ Disposable underpad (if applicable) ❖ Drape (if applicable) ❖ Gloves continues
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continued
PROCEDURAL STEPS
RATIONALE
1. Working in a well-lit area, verify the physician’s order. Be certain to institute the Seven Rights of Drug Administration.
Verifying the physician’s order and following the seven rights will help to prevent errors from occurring.
2. Wash your hands and retrieve the medication and other necessary supplies. Check the label to determine that you have the correct medication prior to removing it from the shelf (Medication check #1).
Washing hands helps to reduce the number of microorganisms on your hands before handling the medication. Checking the label helps to confirm that you have the correct medication.
3. Compare the written drug order with the drug label before preparing the drug (Medication check #2).
Comparing the label against the order verifies that you have the correct medication and the right dose.
4. Check the expiration date of the drug.
Expired drugs may be altered or have deteriorated in their effectiveness.
5. Read the medication label again prior to placing it on the medication tray (Medication check #3).
Checking the label a total of three times will help to ensure that you have the correct medication.
6. Place all other supplies on tray, such as 4x4s, cotton-tip applicators, tongue blades, etc.
Placing items on a tray will aid in transportation of the items.
7. Properly transport the medication to the patient. 8. Identify the patient correctly, using at least two identifiers.
Patient verification is important before administering any drugs to prevent error in administering the wrong drug to the wrong patient.
9. Identify yourself and explain the procedure to the patient.
Explaining the procedure and why you are performing it will encourage patient compliance.
10. Ask the patient to expose the area where the medication is to be applied. 11. Wash your hands and apply gloves.
Washing your hands and applying gloves helps to reduce the amount of microbes on your hands and helps protect you from getting the medication on your own hands.
12. Place a pad under the area on which you are applying the medication.
This will help to protect the patient’s clothes in case there is any dripping.
13. Loosen the lid and remove the cap, placing it so that the inner part is facing upward before placing it on the table.
Placing the lid so that the inside is facing down will contaminate the lid.
14. Remove the appropriate amount of medication from the container using a clean or sterile tongue depressor or cotton-tip applicator.
If it is a sterile procedure, the cream should remain sterile by using sterile supplies.
15. Carefully apply the medication directly over the affected area, working from the inside out (Figure 32-24).
Rubbing or pressure to the surface of the area can disturb any pustules or healing that may have occurred.
FIGURE 32-24 When applying a topical medication to an open area, use a sterile cotton-tip applicator.
FUNDA MENTALS OF PHARM ACOLOGY
PROCEDURAL STEPS
❖
RATIONALE
16. Ask if the patient is experiencing any pain or difficulty in tolerating the application of the medication.
Any unusual pain or burning could indicate a reaction to the medication. Patient safety and comfort should always be paramount when working with patients.
17. Cover the area with a clean/sterile dressing (Figure 32-25) if necessary.
Covering the area with a dressing will keep the medication from being rubbed off onto the patient’s clothing. Use a sterile dressing if it is to be a sterile procedure.
18. Properly dispose of the used disposable supplies.
Proper disposal will help to prevent cross-contamination.
19. Remove gloves and wash your hands.
Handwashing will prevent cross-contamination to other patients and coworkers.
20. Provide the patient with home care instructions and ask the patient to repeat the instructions.
Provding the patient with home instructions will encourage patient compliance.
21. Return the medication to the appropriate cabinet. (Make certain that the outside of the container is clean before replacing it back in storage.)
Cleaning the outside of the container will keep the container from being greasy and promote better handling.
22. Document the procedure in the patient’s chart.
Documentation proves that the procedure was performed.
FIGURE 32-25 Apply a sterile dressing over the area.
DOCUMENTATION EXAMPLE:
09-18-XX 8:10 a.m.
Silvadene ointment applied over burn on patient’s R. forearm with a sterile cotton-tip applicator per Dr. Jones. Sterile nonstick dressing applied to site. Pt. given home care instructions and instructed to call with any concerns or questions. Pt. appeared to understand the instructions. Kim Rippa, CMA (AAMA)
PROCEDURE 32-5 Administer a Transdermal Medication Objective: To administer a transdermal medication to a patient as prescribed by the physician.
Equipment/Supplies: ❖ Written prescription order/patient’s chart ❖ Transdermal medication patch
❖ Gloves
PROCEDURAL STEPS
RATIONALE
1. Working in a well-lit area, verify the physician’s order. Be certain to institute the Seven Rights of Drug Administration.
Verifying the physician’s order and following the seven rights will help to prevent errors from occurring. continues
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continued
PROCEDURAL STEPS
RATIONALE
2. Wash your hands and retrieve the medication, checking the label before removing it from the shelf to make certain you have the correct medication and the correct dose (Medication check #1).
Checking the label helps to ascertain that you have the correct medication and dosage.
3. Assemble the equipment.
Having all equipment assembled in one place will help the procedure to flow much nicer.
4. Remove an unopened transdermal patch from the box.
Removing only what is necessary for the procedure will provide more space to work.
5. Compare the written drug order with the drug label (Medication check #2).
This is to make certain that you have the correct drug and dose.
6. Check the expiration date of the drug.
Expired drugs may be altered or have deteriorated in their effectiveness.
7. Read the directions for proper application of the patch before returning the box to storage if you are unfamiliar with the procedure. Return other patches in the box to their proper storage area. When returning, read the label again to verify that you have the correct drug and dose (Medication check #3).
Application of patches may vary slightly from one manufacturer to the next. Make certain you feel comfortable with the directions before performing the procedure. Reading the label three times will prevent unnecessary errors.
8. Place the unopened patch on a tray and transport the medication to the patient’s room.
Avoid opening the patch until you are in the patient’s room. This will keep the patch intact and prevent the medication from getting on your skin.
9. Correctly identify the patient by using a minimum of two identifiers.
Patient verification is necessary to prevent error in administering the wrong drug to the wrong patient and also complies with Joint Commission safety goals.
10. Introduce yourself and explain the procedure to the patient.
Explaining the procedure will help the patient to relax and encourage compliance.
11. Wash your hands and apply gloves.
Washing hands and gloving helps to reduce the number of microorganisms on your hands and protects your skin from absorbing the medication.
12. Ask the patient to expose the area on which the medication is to be applied. Select an area that is free from hair growth, any lesions, wounds, moles, or rashes. Never place a patch directly over the same site from which a patch was just removed. (Clean the skin with alcohol and allow to dry if the site is dirty or oily.)
Selecting an appropriate site will facilitate better absorption. Placing a patch over the same location from which a patch was just removed may cause irritation to the skin on which the patch was placed.
13. Open the pack and peel off the protective plastic backing of the dermal patch (Figure 32-26). Be careful to ensure that the dermal patch is not accidentally torn or crushed when opening the drug package.
Tears in the patch can cause the medication to leak out, be absorbed too quickly, or ruin the patient’s clothing.
FIGURE 32-26 Peel the plastic backing off of the transdermal patch.
FUNDA MENTALS OF PHARM ACOLOGY
PROCEDURAL STEPS
❖
RATIONALE
14. Gently place the sticky side of the patch on the correct area. Apply gentle pressure to the patch to ensure the patch has adhered to the patient’s skin properly (Figure 32-27).
Good contact with the skin will ensure proper delivery of the medication.
15. Observe the patient for the appropriate time period for any signs of an allergic reaction.
The patient could be allergic to the medication. (Notify the physician ASAP if signs develop.)
16. Properly dispose of the medication package and other disposable supplies. FIGURE 32-27
17. Remove gloves and wash your hands. 18. Provide the patient with verbal instructions and educational brochures and ask the patient to repeat back instructions if the patient is to apply the patch at home.
Giving verbal and written instructions encourages patient compliance.
19. Dismiss the patient and chart the procedure.
Charting the procedure verifies that the procedure was performed.
Apply the patch to the skin and press firmly on all corners of the patch to make certain it is completely adhered to the skin.
DOCUMENTATION EXAMPLE:
03-21-XX 2:15 p.m.
Nitroglycerine transdermal patch, 0.4 mg—applied to upper right chest per Dr. Woo. Observed pt. following administration for any problems. – reactions. Gave pt. home care instructions and instructed pt. to call with any questions. Pt appeared to comprehend instructions. Marcie Littlejohn, CMA (AAMA)
PROCEDURE 32-6 Administer a Rectal Suppository Objective: To correctly administer a rectal suppository as prescribed by the physician.
Equipment /Supplies: ❖ Written prescription order/chart ❖ Rectal suppository ❖ Lubricant
❖ Gloves ❖ Patient gown and drape ❖ Disposable underpad
PROCEDURAL STEPS
RATIONALE
1. Working in a well-lit area, verify the physician’s order and follow the Seven Rights of Drug Administration.
Verification of the physician’s order and following the seven rights will help to prevent errors.
2. Wash your hands and retrieve the medication, checking the label before removing it from the refrigerator to make certain you have the correct medication and the correct dose (Medication check #1).
Checking the label helps to ascertain that you have the correct medication and dosage.
continues
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continued
PROCEDURAL STEPS
RATIONALE
3. Compare the written drug order with the drug label before preparing the drug (Medication check #2).
This is to make certain that you have the correct drug and correct dose.
4. Check the expiration date of the drug.
Expired drugs may be altered or have deteriorated in their effectiveness.
5. Remove the suppository from the box and return the other suppositories back to the refrigerator, checking the label one more time (Medication check #3).
The other suppositories will start to melt if they are not returned to the refrigerator. Checking the label three times will ascertain that you have the correct medication.
6. Place the unopened suppository on a tray with some 4x4s and lubricant. 7. Properly transport the medication to the patient. 8. Correctly identify the patient by using at least two identifiers.
Patient verification is necessary to prevent error in administering the wrong drug to the wrong patient.
9. Identify yourself and explain the procedure to the patient.
Explaining the procedure will encourage compliance and help to alleviate anxiety.
10. Give the patient a disposable gown and a drape to undress for the procedure.
Giving the patient a drape helps to institute modesty.
11. Wash your hands again and apply gloves.
PPE provides protection for the medical assistant from pathogens found in the rectal cavity of the patient. The gloves may also protect the patient from contamination from the medical assistant.
12. Place a disposable underpad on the table for the patient to lie on.
Placing a pad on the table will minimize cleaning and add protection for the office equipment if there is an accidental bowel movement by the patient.
13. Carefully open the foil pack and remove the suppository, being careful not mash it.
The suppository is very slippery and will become easily mashed if handled incorrectly.
14. Instruct the patient to lie in the Sims’ position on the exam table (Figure 32-28).
Positioning the patient on the left side with one leg flexed at the knee will help to expose the buttocks. Caution is to be used to ensure the patient does not fall off the exam table.
FIGURE 32-28 The patient should be placed in the Sims’ position for rectal procedures.
15. Apply lubricant to the suppository tip.
Lubricating the tip of the suppository will ease the insertion into the rectum.
16. Instruct the patient to take in a deep breath and to blow it out as you insert the suppository into the rectum.
Taking in a deep breath and blowing it out helps to relax the sphincter muscles of the anal opening, making the suppository insertion a bit easier.
FUNDA MENTALS OF PHARM ACOLOGY
PROCEDURAL STEPS 17. Gently spread the cheeks of the buttocks with one hand while inserting the suppository with your index or middle finger of the other hand, guiding it past the internal anal sphincter along the side of the rectal wall (Figure 32-29).
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RATIONALE If the suppository is inserted too deeply, you can scratch or injure the rectal mucosa. If the suppository is not placed high enough, the muscle of the sphincter will push the suppository out through the rectal opening before it is properly absorbed.
FIGURE 32-29 Spread apart the cheeks of the buttocks with one hand, while the index or middle finger of the opposite hand guides the suppository into the anus above the internal sphincter along the walls of the rectum.
18. Ask the patient to lie still in the Sims’ position for the amount of time listed in the instructions.
Lying still will keep the suppository from coming back out of the anus.
19. Remove gloves and wash your hands.
This is for infection control purposes.
20. Observe the patient for appropriate reaction to the medication.
The patient should start feeling the effects of the medication relatively quickly.
21. When the proper length of time has been reached for adequate medication absorption, assist the patient into a seated position.
It may take some time before the patient starts to feel the effects of the medication. If the medication is to promote a bowel movement, escort the patient to the bathroom.
22. Document the procedure in the patient’s chart.
Charting the procedure verifies that the procedure was performed.
DOCUMENTATION EXAMPLE:
03/21/XX 2:15 p.m.
Phenergan Suppository, 50 mg, rectally per Dr. Hower. Suppository inserted above the internal sphincter along the rectal wall. Had pt. lie in Sims’ position for 20 minutes following administration. Pt. tolerated well. Symptoms of nausea started to diminish before leaving office. Pt. given home care instructions. Bethany Booker, MA
Chapter Summary Knowledge of pharmacological guidelines and laws is essential in the profession of medical assisting. The medical assistant must understand the level of importance in knowing about different drug uses, routes of administration, and the typical effects patients may have when receiving drugs. It is the responsibility of the medical assistant to know the available resources for obtaining correct information pertaining to pharmaceuticals so the medical assistant can properly administer medication and educate patients. The medical assistant must ensure that all measures of patient safety in medication administration are considered and that all procedures are followed correctly.
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FIELD APPLICATION CHALLENGE The physician orders you to administer a flu vaccine to Mrs. Jones in room 1. You go to the refrigerator and notice that the door is slightly open. The thermometer in the refrigerator is several degrees higher than what it is supposed to be. You look at the log and see that you were the last one to use the refrigerator. Several thousands of dollars of medication is in the refrigerator and may be damaged as a result of this incident. Select one of the options below and state why you would choose the option.
1. The medication is still pretty cool and has only been exposed to the higher temperatures for a short while. Just draw up the medication needed and replace it in the refrigerator, making certain that the door is completely shut this time. 2. Call the manufacturer, explain the concern, and determine if the product can still be used. 3. Immediately alert the supervisor or physician and explain the dilemma.
Chapter Assessment 1. An example of a type of drug that is developed from a mineral source is: a. digoxin. b. insulin. c. sulfonamide. d. hormones.
5. An oral medication that is a liquid form sweetened with sugar and water only is: a. suspension. b. tincture. c. elixir. d. syrup.
2. A drug may have up to three names. The generic name is the drug name based on which of the following? a. The chemical formula that states the molecular structure b. The drug brand name c. The official name of the drug d. Where it falls in the Controlled Substance Drug Schedule
6. How long must inventory records be kept for controlled substances? a. One year b. Two years c. Three years d. Four years
3. Which of the following is a Controlled Substance Drug Schedule II? a. Cough syrup with codeine b. Morphine c. Darvocet d. Heroin 4. What is the minimum number of times a medical assistant must read the medication label when administering the Seven Rights of proper drug administration? a. One b. Two c. Three d. Four
Web Activities 1. Using any of the sites listed below, look up at least two drugs that have been discontinued in the past year. Describe why these drugs were discontinued. • The Federal Drug Administration at http://www.accessdata.fda.gov • Medline Plus at http://www.nlm.nih.gov • Web MD Health Source at http://www.rxlist.com • PDR Health at http://www.gettingwell.com • Drugs.com at http://www.drugs.com 2. Using any of the sites listed above, look up the following drugs and list their classification, use, common adult dosage, common side effects, and contraindications: Procardia, Skelaxin, Toprol XL, Tussionex, Valtrex.
FUNDA MENTALS OF PHARM ACOLOGY
3. Using the pill identification wizard at http://www.drugs.com, type in the word Zithromax. Look at the picture and write a description of the characteristics of Zithromax. 4. Type in the words “drug interaction tool” into any search engine. Click on the related Web site and type in the following two drugs: Percodan and Valium. List the interaction status of these two drugs and give examples of possible complications in mixing these two drugs.
Using your StudyWARE CD-ROM: ❖ Complete the Concentration activity for this chapter. ❖ Complete the Quiz for this chapter in Test Mode.
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THE DVD LINK On your StudyWARE CD-ROM, go to the DVD Challenge for this chapter. View the DVD clip and respond to the following questions: 1. Why did Barb, the office manager, confront Eileen? 2. Do you think that Barb was a little harsh on Eileen? Why or why not? 3. Are medical assistants allowed to dispense controlled substances in your state?
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C H A P T E R
Dosage Calculations
Essential Terms
Chapter Outline Medication Order Medication Math Fundamentals The Apothecary System The Metric System Household Measurements Calculating Drug Dosages for Administration Rounding Equations
33
Proportional Method Formula Method Calculating Pediatric Dosages Calculating Insulin Dosages Types of Insulin Reading Medication Labels Warning Labels
Developmental Objectives After completing this chapter, you should be able to: 1. Correctly spell and define the essential terms. 2. Demonstrate and perform conversions between the various systems of measurements. 3. Correctly calculate an adult dose of medication based on the order given and the label. 4. Calculate children’s dosages according to body surface area (BSA) and according to kilograms of body weight. 5. Describe what insulin is measured in and what type of syringe is used. 6. List and describe the types of insulin that are available. 7. List the important parts of a medication label and describe what should be checked every time a medication is administered.
apothecary apothecary system body surface area (BSA) conversion drug dosage expiration date generic name gram (g, gm) liter (L) lot control medication label meter (m) metric system National Drug Code (NDC) nomogram prescription product name
D O S A G E C A LC U L AT IO N S
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Introduction Medical assistants are often called upon to prepare medications. In order to properly prepare a medication, the medical assistant must be able to read and comprehend the physician’s order, read and comprehend the medical label, and calculate the appropriate dose. The medical assistant should be able to educate patients on how to take medication and assist the patient with understanding the different types of warning labels that appear on medication bottles. This chapter will provide a review of fundamental math principles and will introduce math formulas that are necessary for calculating medication dosages. Learning the information in this chapter is vital to patient safety and the patient’s overall well-being.
MEDICATION ORDER Medical assistants are often assigned the task of administering medications to patients while they are in the office. They may also be responsible for dispensing medications and creating or calling in prescriptions for patients. In order to perform these tasks, the medical assistant must be familiar with the information included in a medication order. A medication order is an order that includes the following: ❖ ❖ ❖ ❖ ❖
Name of the drug to be administered, dispensed, or prescribed Drug form Drug dosage Frequency of administration Special instructions for taking the medication
The physician is usually the health care team member responsible for creating medication orders; however, other providers in the practice—including nurse practitioners and physician’s assistants—may also create medication orders. Because medical assistants are not licensed, they must be familiar with delegation laws for administering medications in the states in which they work. Many medical practice statutes dictate that only a physician can delegate the administration of parenteral medications to an unlicensed individual, which would include the medical assistant. It is important to check these laws before proceeding with such tasks.
MEDICATION MATH FUNDAMENTALS In order to calculate medication dosages, medical assistants must have an understanding of basic math principles. Some math skills that are necessary for calculating dosages include the ability to perform metric conversions and set up and solve equations (formulas). There are two major systems used to calculate medication dosages: the apothecary system and the metric system. The apothecary system was the original primary method used for calculating and measuring medication dosages; however, the metric system is now considered the primary method.
The Apothecary System A pharmacist or chemist was formerly known as an apothecary. The traditional math system that was used to determine medication dosages in English-speaking countries was known as the “apothecary system of mass.” This system was replaced by the metric system during the first half of the twentieth century. Since this
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system is not commonly used in today’s medical office, we will not elaborate on this system.
The Metric System Prior to the early 1800s, there was no standardization between countries in regards to units of measurement. Each country had its own units for measuring, which made it very difficult when trading, buying, or selling. In the late 1700s, the French National Assembly called upon the Academy of Science to create a simple, decimal-based system of units that could be used by people in all countries. Members of the Academy went to work and carefully reviewed proposals submitted by scientists throughout France. In 1801, the French National Assembly adopted a decimal-based system based on the circumference of the earth submitted more than a century before by a French scientist by the name of Gabriel Mouton. The system that Mouton created is today referred to as the metric system. It took several years for other countries to adopt the system, but the metric system is now considered the primary method for measuring weight, volume, and length (area) throughout the world. In the United States, scientific measures and formulations are based on the metric system, though other systems of measurement, such as apothecary measurements and the household system, may be used as well. The metric system has evolved into the modern system known as Le Système International d’Unités (SI), or International System of Units, which is the primary method of measurement in medicine.
Metric System Weights and Measures
can easily be converted into other units by simply moving the decimal place (milliliters to liters and grams to micrograms, for example). There are 14 prefixes that are used within the metric system to describe the size of a metric unit; however, only a portion of those are used in health care. Table 33-1 lists the most common prefixes and their standard values.
Units of the Metric System The three fundamental units used in the metric system are liters, meters, and grams. Meter (m), the fundamental unit of length, is used when measuring distance. It was the initial unit of the metric system and set the foundation for the remainder of the system. Centimeters (cm) are often used when measuring lesions, moles, wheals, and the diameter of burns and lacerations. Liter (L) is the fundamental unit of volume and is used when measuring liquids. One milliliter is equivalent to one cubic centimeter (cc). This is because the amount of space that is needed to occupy a milliliter is equivalent to one cubic centimeter; hence, these terms
TOOL BOX
FI E L D S M A R T S Because the abbreviation “cc” (cubic centimeter) has been placed on the ISMP’s List of ErrorProne Abbreviations, it should no longer be used when documenting in a patient’s chart. Use mL instead.
The metric system is referred to as a decimal-based system because it is based on multiples of 10. Metric units TABLE 33-1 Common Prefixes and Their Values UNIT
PRONUNCIATION
UNIT VALUE
DECIMAL VALUE
micro-
mikro
1/1000,000 of a unit
0.000001
milli-
mili
1/1000 of a unit
0.001
centi-
senti
1/100 of a unit
0.01
deci-
desi
1/10 of a unit
0.1
deka-
deka
10 units
10
hecto-
hekto
100 units
100
kilo-
kilo
1000 units
1000
D O S A G E C A LC U L AT IO N S
may be used interchangeably. Injectables and liquid medications are measured in liters (specifically, milliliters) when using the metric system. Gram (g, gm) is the metric unit that is used when measuring anything that has mass or weight. One gram weighs approximately 1 cubic centimeter. Solid medications are often recorded in subunits of grams (mg or mcg) and the patient’s weight is recorded in kilograms (kg). Table 33-2 illustrates common metric units that are used in medicine and gives examples of how they are used.
Metric System Guidelines The following guidelines have been provided to assist in learning how to use the metric system correctly: 1. For all units except liters (L), use lowercase letters: mg, g, mm, mL. 2. Always leave a full space between the number and unit: 2 mL, 5250 km. 3. According to the international convention, there should be no commas when writing long numbers: 25 232 (not 25,232). 4. Avoid mixing symbols with names that are spelled out in the same expression: Correct 8 kg/L 10 kilograms per liter
Incorrect 8 kg/liter 5 kg per L 10 kilograms/liter
5. Arabic numbers are used to denote whole numbers: 1, 10, 100, 1000. 6. Fractions are converted to their decimal equivalents for quantities less than 1: 0.1, 0.05, 0.005.
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7. A zero should always be placed before a decimal point for numbers less than 1 to avoid confusion: 0.1, 0.05, 0.001. 8. Metric units do not have a singular or plural form: 5 mL, 2 mL, 60 mg (no “s” at the end). 9. The Arabic number always precedes the metric unit of measurement: 10 grams, 2 milliliters, 5 liters. 10. Gram is abbreviated by writing gm or g. The preferred abbreviation is g. 11. When a measurement/symbol is named after a person, capitalize the measurement and symbol: Celsius (C). By combining prefixes with the roots, you get multiples or submultiples of the metric system. For example, milli- (prefix) and liter (root) are combined to form milliliter (refer to Table 33-3).
Metric Conversions The term conversion means to switch from one unit to another. Conversion may be necessary when the physician orders a medication in a unit that is not available, such as when the physician orders a drug in milligrams and the measurements on the drug label measure the drug in grams. There are a number of different methods that can be used to perform conversions—two are presented here. Conversion Factor Method The conversion factor method can be used both for performing conversions within the metric system and for performing conversions between two different systems. To perform conversions using the conversion factor method, a factor equivalent table will need to be available to use when setting up problems. Table 33-3
TABLE 33-2 Common Metric Units Used in Health Care MEDICATION DOSAGES ARE USUALLY MEASURED IN
MEDICATION VOLUMES ARE USUALLY MEASURED IN
LABORATORY RESULTS ARE USUALLY MEASURED IN
Grams (gm, g) Milligrams (mg) Micrograms (mcg) Units (U) (“U” is an error-prone abbreviation; write out “units” instead.)
Milliliters (mL) Cubic centimeter (cc) (“cc” is an error-prone abbreviation; use mL instead.)
Milligrams (mg) Micrograms (mcg) Grams per deciliter (g/dL) Units per liter (U/L)
MISCELLANEOUS Blood pressure is measured in milliliters of mercury (mm Hg). Wounds and lesions are usually measured in centimeters (cm). Organs are usually measured in grams (g).
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TABLE 33-3 Common Units Used in the Metric System LENGTH: METER
VOLUME: LITER
0.001 of a meter 1 millimeter (mm)
0.001 of a liter 1 milliliter (mL)
0.01 of a meter 1 centimeter (cm)
0.01 of a liter 1 centiliter (cL)
0.1 of a meter 1 decimeter (dm)
0.1 liter 1 deciliter (dL)
1 meter 1 meter (m)
1 liter 1 liter (L)
10 meters 1 dekameter (dam)
10 liters 1 dekaliter (daL)
100 meters 1 hectometer (hm)
100 liters 1 hectoliter (hL)
1000 meters 1 kilometer (km)
1000 liters 1 kiloliter (kL)
MASS AND/OR WEIGHT: GRAM
FREQUENTLY USED METRIC EQUIVALENTS
0.000001 gram 1 microgram (mcg)
2.54 centimeters (cm) 1 inch (in)
0.001 of a gram 1 milligram (mg)
1000 millimeters (mL) 1 liter (L)
0.01 of a gram 1 centigram (cg)
1000 cubic centimeters (cc) 1 liter (L)
0.1 of a gram = 1 decigram (dg)
1000 micrograms (mcg) 1 milligrams (mg)
1 gram = 1 gram (g)
1000 milligrams (mg) 1 gram (g)
10 grams 1 dekagram (dag)
1000 grams (g) 1 kilograms (kg)
100 grams 1 hectogram (hg)
1 kilogram (kg) 2.2 pounds (lb)
1000 grams 1 kilogram (kg)
is a factor equivalent table for the most common metric system units. (Be very careful when using a factor equivalent table. Pay attention to detail to avoid setting the problem up the wrong way.) Example: 5 g _____ mg Step 1. Write down the initial measurement and place it over the number 1 (you are creating a fraction—the initial measurement becomes the numerator, and the number 1 is the denominator). Next to this, create a second fraction. Place the number 1 beside the units you want to convert to (in this case, mg). This will be the numerator in the second fraction. Proceed to Step 2 to add the denominator to the second fraction. 5g 1
1 mg
_____ mg
Step 2. The denominator of the second fraction is the converting factor from the appropriate factor equivalent table, the factor that matches the unit of the initial measurement to the units necessary for the final measurement. Referring to Table 33-3, the factor equivalent for this problem is 0.001 g 1 mg. Place 0.001 g as the
denominator of the second fraction. Note that the units you want to eliminate (in this case, grams) must be in opposite positions (numerator and denominator) so they cancel out; otherwise, you have set the problem up incorrectly. 5g 1
1 mg _____ mg 0.001 g
Step 3. Multiply the two numerators and the two denominators. Note that the grams are in opposite position and therefore cancel each other out. 5g 1 mg 5 mg 1 0.001 g 0.001 Step 4. Divide the numerator by the denominator. 5 mg 5000 mg 0.001 The answer is 5 g 5000 mg. Shortcut or Counting Method Another method that can be used when performing conversions within the metric system is the shortcut or counting method. Since
D O S A G E C A LC U L AT IO N S
the metric system uses multiples of 10, it is relatively easy to perform conversions within the metric system, because all you are doing is moving the decimal point a specific number of places to the right or to the left. Table 33-4 is a metric conversion table that can be used when performing metric conversions. It illustrates the common metric units used in health care and their values in descending order. The bottom row of the table has a counting section with arrows. The arrows point to the metric unit that each arrow represents. This is the section used to determine how many places and in which direction to move the decimal. To illustrate how to use this table, use the following metric conversion problem: Example: 1 g _____ mg 1. Start by placing your finger in the box of the arrow that represents the unit of the known value. (For this problem, place your finger in the box above the arrow for the Standard Unit, gram.) 2. Next, move your finger the number of places that it takes to get from the known value to the unknown value. (In this case, move from grams to milligrams, which is three places to the right.) 3. Next, move the decimal in the number of the known value the number of places that it took to get from the known value to the unknown value. The decimal in any whole number is immediately to the right of the whole number. (For this prob-
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lem, add three zeros, since you moved three places to the right.) The answer is 1 gram 1000 mg. It gets a little trickier when you move the decimal from the right to the left. Convert the following unit: Example: 5 mg _____ g 1. Place your finger on the arrow that represents the prefix milli-. 2. Next, move your finger the number of spaces that it takes to get from milli- to grams. (You should have moved your finger three places to the left to move from milli- to grams.) 3. Next, move the decimal in the number of the known value the number of places that it takes to get from the known value to the unknown value. (So move your decimal point three places to the left.) Since the decimal point immediately follows the whole number, moving the decimal one place would represent 0.5 g, moving the decimal two places would represent 0.05 g, and moving the decimal three places represents 0.005 g. The answer is 5 mg 0.005 g or 5/1000 of a gram.
Household Measurements The imperial system (also known as the household system) of measuring volume and weight can be found in any kitchen in the United States. This system is
TABLE 33-4 Metric Conversion Table WHOLE NUMBERS
FRACTIONS OR DECIMALS
➙
➙
—
1/1,000,000 0.000001
kilo
hecto
deka
Standard Unit (gram, liter and meter)
deci
centi
milli
PH*
PH*
micro
—
—
➙
—
➙
1/1000 0.001
➙
1/100 0.01
➙
1/10 0.1
➙
1
➙
10
➙
100
➙
1000
➙
DECREASING VALUE
➙
INCREASING VALUE
PLACE HOLDER COUNTING SECTION *The letters PH stand for “place holder.” The majority of metric units are separated by one unit of 10; however, the separation between milli- and micro- jumps from 10 to 1000. So that you don’t get confused, place holders between milli- and micro- are there as a reminder to move the decimal place three places between the two units.
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TOOL BOX
CR ITI C A L TH I N K I N G C H AL LEN G E Using either the conversion factor method or the shortcut method, convert the following measurements: 1. 0.25 grams _____ milligrams 2. 750 micrograms _____ milligrams 3. 1 kilometer _____ meters 4. 1 liter _____ microliters
important to the patient who has no prior experience working with the metric system. Most Americans will be familiar with this system because they use it in their everyday lives. Household measurements may be used as reference points during patient education. The medical assistant should always keep in mind that household measurements are not exact and should not be used in a clinical setting. The household system measures weight in increments called pounds, and volume is measured in drops (gtt). Pounds are still the standard unit for patient weight in the United States. Liquid oral medications can be easily measured and are sometimes prescribed in household units such as
teaspoon, tablespoon, drops, and ounces. (Keep in mind that many pharmaceutical manufacturers are now packaging their liquid medications with droppers or medication cups that feature both household and metric units.) Table 33-5 lists some of the most common household measurements. Some common conversions between the household system and the metric system can be found in Table 33-6.
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C R I T I C A L T H I N K I NG CHALLENGE Using Table 33-6 as a reference, read and respond to the following: A patient is concerned because her mammogram stated that she had a 0.6 cm lesion in her right breast. There is no indication that the lesion is cancerous. The patient appears to be more upset about the size of the lesion than anything else and keeps referring to the size as 0.6 inches. 1. How might you comfort the patient based on the conversion in Table 33-6? 2. Should this patient be referred to the physician?
TABLE 33-5 Common Household Measurements 60 drops 1 teaspoon (tsp) 1 dash less than 1/8 tsp 3 teaspoons 1 tablespoon (tbsp) 2 tbsp 1 ounce (oz) 4 oz 1 juice glass 6 oz 1 teacup 8 oz 1 glass or cup 16 tbsp or 8 oz 1 measuring cup 2 cups 1 pint 2 pints 1 quart 4 quarts 1 gallon
TABLE 33-6 Common Conversions between Household Measurements and Metric Measurements HOUSEHOLD MEASUREMENT
METRIC MEASUREMENT
1 teaspoon (tsp) and 1 dram
5 cc or 5 mL
1 tablespoon (tbsp)
15 cc or 15 mL
1 ounce (oz)
30 cc or 30 mL
1 cup (c)
180 cc or 180 mL
1 glass or 8 ounces (oz)
240 cc or 240 mL
2.2 pounds (lb)
1 kilogram (kg)
1 inch (in)
2.5 centimeter (cm)
D O S A G E C A LC U L AT IO N S
CALCULATING DRUG DOSAGES FOR ADMINISTRATION It is important for the medical assistant to be able to properly calculate medication dosages. An error in medication dosage can cause great harm to the patient. There are two major methods used for calculating adult dosages: the proportional method and the formula method. The method you will use will be the one that is most comfortable for you.
Rounding Equations There will be some occasions when it will be necessary to round your answers to obtain the correct dosage. Table 33-7 illustrates guidelines for rounding adult dosages. Because young children are so tiny, rounding becomes much more complicated. Always check the physician’s preference when rounding for children.
Proportional Method Some people prefer to use the proportional method when calculating dosages. The steps are listed below: Example: The physician orders 0.75 g of Luvox. The medication on hand is 500 mg tablets. Step 1. Determine if the ordered dose is in the same units as the dose on hand. If not, convert so that the two are in the same units before calculating the dosage.
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FI E L D S M A R T S Cutting tablets that are not scored is highly inadvisable; it is very difficult to cut the pills into two even halves. Always use a pill splitter for the most accurate measurement.
Change 0.75 g to mg using the conversion factor formula. (Hint: 0.001 g 1 mg.) 0.75 g 1 mg 0.75 mg 1 0.001 g 0.001 0.75 g
750 mg
Step 2. Next, set up a proportion to calculate the dosage. Unit on hand : Medication form Dosage ordered : Unknown amount to be given 500 mg : 1 tab 750 mg : x tab Step 3. Remember that a proportion is the same as a fraction, so this can be written as: 500 mg 1 tab
750 mg x tab
TABLE 33-7 Guidelines for Rounding Adult Dosages LIQUIDS
SOLIDS
1. Round to the nearest tenth when giving more than 1 mL of medication. (Use a 3 mL syringe, marked in tenths.)
1. When working with tablets that are not scored, round to the nearest whole number of what is available. If your calculation comes out to 1.8 tablets, you will round up and give the patient 2 tablets. (Always check with the physician for clarification, however.)
2. Round to the nearest hundredth when giving less than 1 mL. (Use a TB syringe marked in hundredths.) 3. For digits 1 through 4, round down. For digits 5 through 9, round up. For example, 1.42 mL would be rounded to 1.4 mL, and 1.78 mL would be rounded to 1.8 mL.
2. If you are working with tablets that are scored (grooved), round to the nearest half or whole tablet. For example, if your answer is 1.5 tablets and the tablets are scored, you will give the patient 11⁄2 tablets.
Note: When performing multiple step problems, wait until the last step to round. If two separate problems are necessary to obtain an answer, round the last step of each problem. All weights should be rounded to the nearest hundredth. For example, 25.256 kg 25.26 kg.
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Step 4. Cross multiply the numbers. This means to multiply the numerator from the left fraction with the denominator of the right fraction, and vice versa. 500x 750 Step 5. Solve for x. To solve for x, divide both sides of this equation by 500. This leaves just “x” on the left side of the equation. 500x 750 500 500 x
750 500
x 1.5 The answer is 1.5 tablets should be given. Step 6. To check whether your answer is correct, insert your answer into the original formula in place of x and cross multiply. 500 mg : 1 tablet 750 mg : 1.5 tablets 500 mg 750 mg 1 tab 1.5 tab 500 1.5 750 1 750 750
Formula Method
C R I T I C A L T H I N K I NG CHALLENGE Calculate the following dosage problems using either the proportional or formula method: 1. Order: 500 mg of Cipro (ciproflaxin HCL). Available: 250 mg tablets. Amount to be given? 2. Order: 50 mg of Thorazine. Available: 25 mg/mL. Amount to be given? 3. Order: 100 mg of Terramycin (oxytetracycline) IM. Available: 50 mg/mL. Amount to be given?
Step 2. Set up the equation: 50 mg (Desired) 1 mL 25 mg (Available) 50 1 mL 25 2 1 mL 2 mL (The unit mg cancels out.)
The formula method of calculating adult dosages requires the use of the following mathematical formula: Amount Desired Amount Available
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Quantity (how it comes stocked, for example: l mL, l cap)
The following steps can be used to calculate dosages using the formula method: 1. Determine if the dose desired is in the same units as the dose available or on hand. If not, convert so that they are in the same units. 2. Next, use the formula listed above to calculate the dosage. 3. Round the calculation using the criteria listed in Table 33-7. Example: The physician orders 50 mg of Demerol. It comes stocked as 25 mg/mL, which means that there are 25 mg of Demerol in 1 mL of medication. Step 1. The desired amount is already in the same units as the available amount, so no conversion is necessary.
The answer is the patient should receive 2 mL of Demerol. (There is no need to round this answer.)
Calculating Pediatric Dosages Because children are continuously growing, their size and weight must be considered when calculating pediatric dosages. The two common methods used to calculate the proper drug dosages for a pediatric patient are based on body surface area (BSA) and by kilograms of weight.
Calculating Pediatric Dosage by Body Surface Area (BSA) The medical industry considers the body surface area (BSA) the most accurate method of calculating drug dosages for infants and children up to 12 years of age. In order to use this method, the child’s height and weight must be known. A nomogram (Figure 33-1) is a graph that illustrates a relationship between two known values. The BSA is figured by drawing a straight line from the patient’s height to the patient’s weight. Where the numbers intersect on the surface area (SA) line is the figure that is used for the BSA. The BSA is
D O S A G E C A LC U L AT IO N S
in
90 80 240 220 200 190 180 170 160 150 140 130
90 85 80 75
70 60
1.00
50
0.90
40 65
0.70
60 30 55
100
40
90
35
Weight (lb)
45
0.60 0.55 0.50
50
110
20
0.45 0.40
15
0.35 0.30
80 30 28
10 9
26 60
2.0 1.9 1.8 1.7 1.6 1.5 1.4 1.3 1.2 1.1 1.0
0.80
70
120
70
1.30 1.20 1.10
24 22
0.25
8 7 6
Weight
m2
0.9
Surface area (square meters)
cm
SA
For children of normal height for weight
0.8 0.7 0.6 0.5
0.4
lb 180 160 140 130 120 110 100 90 80 70 60
50
40
20 19 18 17 16
4
15
60 50 40
30
20
30
15
25
14
10 9.0 8.0 7.0 6.0
0.3
0.20
0.2
5.0 10 9 8
4.0 3.0
6 5
0.15
2.0
3
1.5
0.10 2
0.1
Example: 21 mg 21 1 mL 0.42 mL 50 mg 50 (Remember that anything less than 1 mL when rounding liquids is rounded to the nearest hundredth.)
Calculating Pediatric Dosage by Kilogram of Body Weight Another way to calculate pediatric medication dosages is based on kilograms of body weight. Refer to the steps below:
2.5
4
3
13 12
70
12
14
30
80
25
7 5
kg
50 45 40 35
20 18 16
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Amount Desired Quantity Amount Available
NOMOGRAM Height
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1.0
FIGURE 33-1 Information provided by the nomogram can help with dosage calculations.
then placed in the formula (equation) below to determine the proper dosage for the child. BSA of Child in m2 Adult Dose Child’s Dose 1.7 (m2) This formula is based on the average adult who weighs 140 lb and has a body surface area of 1.7 square meters (1.7 m2). Example: Michelle Turner is a five-year-old child who is 40 inches tall and weighs 38 lb. Find her BSA on the nomogram (BSA 0.7). The physician has ordered Demerol for pain. The average adult dose of Demerol is 50 mg/mL. What dosage would be correct for Michelle according to the BSA method? Child’s Dose 0.7 m 50 mg (round dose to the nearest 1.7 m2 whole number) 2
0.7 m2 35 20.5 mg 50 mg (rounded 21 mg) 2 1.7 1.7 m Once it has been determined that the pediatric patient is to get a 21 mg dosage of medication, it can be plugged into the formula used for calculating adult doses. For example, if the label reads that there is 50 mg/mL of medication, convert mg to mL using the following formula:
1. Convert pounds into kilograms by dividing the number of pounds by 2.2. (Round the answer to the nearest hundredth.) 2. Multiply the dose ordered by kilogram of body weight. 3. If applicable, divide the child’s dose by the number of equal doses to be given in a 24-hour period. Example: The physician orders ceftriaxone sodium (Rocephin) 50 mg/kg. The medication should divided into equal doses every 12 hours (not to exceed 4 g) for Sandy Porter, who weighs 66 pounds. How many milligrams will Sandy receive? 1. Convert the pounds to kilograms. (In this case, no rounding is necessary.) 66 lb 30 kg 2.2
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C R I T I C A L T H I N K I NG CHALLENGE 1. A child has a BSA of 0.5. The adult dose is 250 mg. How many mg of medication should the child receive? The label on the bottle states that there is 100 mg/mL of medication. How many mL should the child receive? 2. A child has a BSA of 0.8. The adult dose is 500 mg. What would be the correct dosage for this child? The label reads that there is 500 mg/2 mL of medication. How many mL of medication should the patient receive?
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2. Multiply the dose ordered by the weight in kilograms. (Cancel out like units.) 50 mg 30 kg 1500 mg 1.5 g kg 3. If applicable, divide the child’s dose by the number of equal doses to be given in a 24-hour period. Divide 1500 mg by 2 to obtain the divided dose 750 mg The answer is Sandy will receive 750 mg of Rocephin every 12 hours, as ordered. (Note that this does not exceed 4 grams.)
CALCULATING INSULIN DOSAGES Insulin is measured in units and should be administered with a U-100 syringe. U-100 means that there are 100 units in one milliliter or cubic centimeter of medication. Never use a standard ml/cc syringe when administering insulin. The physician will determine the exact number of units to be given to the patient. Because of the role that insulin plays in the body, an error in dosage can lead to serious complications or even death. Because there are so many types of insulin, make certain that you have the correct type by reading the label thoroughly. When mixing insulin, make certain that the two are compatible. Start with clear and move to cloudy.
include: Humulin R, Crystalline Zink, Humalog, Semilente, Velosulin, and Novolin. ❖ Intermediate acting insulin: This means the action falls between the rapid acting and long acting insulin, usually between 30 minutes to 11⁄2 hours. Examples include: NPH, Lente, Humulin N, and Novolin N. ❖ Long acting insulin: This type of insulin takes the longest to exert its effects, usually 4 to 24 hours. Examples include: Ultralente, PZI or Protomaine Zink Insulin, and Insulin Glargine.
READING MEDICATION LABELS The medication label is the product label that gives vital information about the medication. Medications normally come with an insert that has additional information that may be helpful in administering the medication. Medical assistants must be able to read and understand medication labels so that they can properly administer medications. Figure 33-2 shows an example of a nonprescription product label that contains the following:
❖ Rapid acting insulin: This means that its action is very quick, usually within 15 to 60 minutes of administration. Examples of rapid acting insulins
Prescription medication labels are a little different than nonprescription labels. A prescription is an order for a prescribed drug. Prescription labels include
Types of Insulin
E M R A P P L I C AT I O N Some EMR programs feature an electronic dosage calculator within the software, which calculates the dosage after you enter the required information into the appropriate fields. There are also electronic dosage calculators available on the Internet (search for “online dosage calculators”).
However, do not rely on the answer you receive from an electronic calculator. Always work the problem out first manually, and use the electronic calculator to check your work. This will help ensure you have the correct dose.
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There are three different types of insulin. They are named by how quickly they are absorbed in the bloodstream.
❖ A description of the tamper-resistant feature. ❖ The product name and dosage amount (if applicable) ❖ The active and inactive ingredients. Sometimes, this information appears on the medication insert. ❖ The quantity of the solution. ❖ The name and address of the manufacturer, packer, or distributor ❖ The back of the label lists indications for use, dosage instructions, warnings, interaction problems, lot number, and expiration date.
D O S A G E C A LC U L AT IO N S
Description of tamperresistant feature Product name statement of identity
Listing of active ingredients
Listing of inactive ingredients
Net quantity of contents
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EAL ER EER S KLE L KL ER SEA SEA R EAL KLE S E R KLE KLEE E AL ER SEA E L S K L EA ER EER S KLE L KL LEER SEA SEA K L A R E E EER S KLE L KL ER SEA SEA EAL KLE ER EER S L KLE K E AL ER SEA S E L ER SEAL K LEER KLE AL K A E S E L K t n i n i r g p f K i leAeLr Seal ER SE Do nEoRt use E band around cap and neck is broken or missing!
ANTACID LIQUID •Pleasant Tasting • Soothing •Non-Constipating One teaspoon contains: Magnesium Hydroxide 200 mg Aluminum Hydroxide 200 mg (equivalent to dried gel U.S.P) Also: citric acid, mannitol, methylparaben, natural, propylparaben, saccharin, sodium, sorbital, purified water 12 FL. OZ. (355 ML) Dann's Medicines Inc. Washington
Name and address of manufacturer, packer, or distributor
Indications for use
Directions and dosage instructions
Warnings and cautionary statements
Drug interaction precaution
Expiration date and lot or batch code
EAL ER EER S KLE L KL EA SEA L KLEER S ER R SEA E E E L L K LK EA SEA L KLEER S A R E S E R KLE KLEE EA S R E AL E E L S K L ER R SEA KLE KLEE E AL R SEA E E S L K L EA ER EER S KLE L KL EA SEA L KLEER S ER R SEA E E L KLE LK ER SEA SEA EAL KLE ER ELL BEFOR
E USING SHAKE W A specially blended combination of two antacids: magnesium hydroxides and aluminum hydroxide for the temporary relief of heartburn, sour stomach, and acid indigestion. Directions: One or two teaspoonfuls as needed every two to four hours between meals and at bedtime, or as directed by a physician. Warnings: Except under the advice and supervision of a physician, do not take more than 24 teaspoonfuls in a 24-hour period or use the minimum dosage of the product for more than two weeks. Warning: Keep this and all drugs out of the reach of children. In case of accidental overdose, seek professional assistance or contact a poison control center immediately. Sodium Content: This product contains less than 14 mg sodium in each two teaspoonfuls. Drug Interaction Precaution: Do not take this product if you are presently taking a prescription antibiotic containing any form of tetracycline.
EXP. 5/10 8M12
FIGURE 33-2 Information found on a nonprescription label
vital information for the person dispensing the medication (Figure 33-3). Some specific parts of a prescription medication label include: ❖ Product name (Vistaril): Refers to the trade name or brand name of the medication. ❖ Generic name (if applicable) (hydroxyzine hydrochloride): This is the drug’s official name; it can also be a listing of active and nonactive ingredients within the medication.
❖ National Drug Code (NDC) (0049-5460-74): These are the numbers used to identify the manufacturer, the product, and the size of the container. ❖ Dosage strength (50 mg): This is the dosage strength for each unit. ❖ The drug form (liquid): This is the form in which the drug is supplied. ❖ The number of units (10 mL), or total volume: The number of units, capsules, mL, or tablets in the entire bottle.
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❖ Usual dose and frequency (25 to 100 mg every four to six hours): The usual dosage administered to the patient in one dose and how often the dose is administered. ❖ Route of administration (intramuscular): This information indicates how the medication is to be given: IM, sub-q, topically, rectally, etc. ❖ Manufacturer’s name (Pfizer Roerig) ❖ Expiration date (shown on Figure 33-4: 8/2012): The manufacturer only guarantees the effectiveness and safe use of the medication up to the expiration date posted on the drug package or container. If a drug is expired, it should be disposed of properly. ❖ Lot control or batch number (shown on Figure 33-4: 401803c): The manufacturer places a lot control or batch number on the label in order to track medications in the event that a bulk production of the drug is recalled due to numerous reports of severe adverse reactions or product contamination. ❖ Other information (refer again to Figure 33-3): Drug storage information (store below 86°F [30°C]; do not freeze), photosensitivity information, and so on.
Warning Labels Warning labels are placed on medications indicating special instructions for proper and effective usage of the drug. Patients must be informed of medication side effects, such as drowsiness or dizziness, which could make driving or operating machinery dangerous. Other warning labels may include instructions on how or when to take the medication. Examples include instructions to take the medication with food to lessen gastric distress or to take on an empty stom-
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C R I T I C A L T H I N K I NG CHALLENGE Using the product label in Figure 33-4, answer the following questions: 1. What is the product name? 2. What is the expiration date on the bottle? 3. What form does the medication come in? 4. What is the dosage amount for the medication? 5. Who is the manufacturer?
ach due to interference with the drug’s absorption or effectiveness. Additionally, warning labels may instruct patients to take their drugs with lots of water, to refrigerate the medication between doses, and even to shake the bottle well to resuspend the particles of some medications. Figure 33-5 illustrates a variety of instructions and warning labels for prescription medications.
FIGURE 33-4 Furosemide Injection (Courtesy of Abraxis.)
FIGURE 33-3 Prescription drug labels contain vital information regarding the medication. (Courtesy of Roerig, a division of Pfizer, Inc.) 8/2012
D O S A G E C A LC U L AT IO N S
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FIGURE 33-5 Warning labels and instruction labels used on prescription medications
Chapter Summary Proper administration of medications begins with the ability to read and interpret the medication order. Having a good foundation in math and an understanding of how to use dosage formulas is a must for calculating dosages properly. Making an error in a medication dosage can cause great harm or even death to the patient. Medical assistants should practice these skills while still in training in order to be comfortable with dosage calculations upon entering their externships. Patient education regarding how to properly take medications is another important role of the medical assistant. Patients that are well informed will have a much better chance of being compliant, which means healthier, happier patients in the long run.
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FIELD APPLICATION CHALLENGE The physician orders you to give the patient 1000 mg of ibuprofen po. The bottle states that it contains 250 mg tablets. How many tablets will you need to give to the patient? The patient states that she has a hard time swallowing pills and does not want to take them. You have poured them into the medication cup but not into the patient’s hand. Can
you pour them back into the bottle? Why or why not? You notice that there is also an injectable for the ibuprofen. The label on the container reads that there is 500 mg/mL of medication. How many mL will you give? Will you need to ask the physician if it is okay to give the patient an injectable instead of an oral medication? Why or why not?
Chapter Assessment 1. The fundamental units of the metric system include all of the following except: a. meters. b. liters. c. pounds. d. grams.
5. What chart is used to calculate dosages using the BSA method for pediatric patients? a. Metric chart b. Nomogram chart c. Household measurement chart d. No chart is necessary
2. A physician orders Amoxicillin 500 mg PO stat. On hand you have 250 mg/1 tab. How much medication is to be administered to the patient? a. 1⁄2 tablet b. 1 tablet c. 11⁄2 tablets d. 2 tablets
6. Components of a medication label include all of the following except: a. the generic name of the medication. b. the price of the medication. c. the manufacturer of the medication. d. the listing of active ingredients.
3. What is the decimal form that represents one/one hundredth? a. 1/100 b. 0.01 c. 0.1 d. 1/10 4. When should household measurements be used? a. In a clinical setting b. When you can’t do the conversion calculation c. When you want an exact dosage calculated d. When assisting patients with medication that they will administer at home
Web Activity 1. Using a Web article from a professional nursing periodical or other health magazine, write a onepage paper on how to prevent medication errors.
CONNECTION Using your StudyWARE CD-ROM: ❖ Complete the Hangman activities for this chapter. ❖ Complete the Quiz for this chapter in Test Mode.
C H A P T E R
Administration of Parenteral Medications Chapter Outline Administration of Parenteral Medications Parenteral Equipment and Supplies Preparing Medications General Guidelines for Parenteral Medications Routes of Administration Intradermal Injections Subcutaneous Injections Intramuscular Injections Parenteral Complications
Immunizations Contraindications and Precautions in Vaccine Administrations Basics of Intravenous Therapy Equipment and Supplies Employed in Intravenous Therapy Documentation of IV Therapy Risks, Complications, and Adverse Reactions of IV Therapy Discontinuation of Intravenous Infusion Therapy Intra-articular Injections
34 Essential Terms ampule aqueous aspirate bolus cannula cartridge unit cubic centimeter (cc) diluent extravasation gauge hypodermic infiltration intra-articular intradermal intramuscular (IM) Luer-Lok occlusion parenteral patency phlebitis precipitate primary drug secondary drug continues
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KEY COMPETENCIES
CAAHEP
ABHES
Withdraw Medication from a Vial
III.C.3.b.4.g
VI.A.1.a.4.m
Withdraw Medication from an Ampule
III.C.3.b.4.g
VI.A.1.a.4.m
Reconstitute a Powdered Base Medication with a Diluent
III.C.3.b.4.g
VI.A.1.a.4.m
Mix Two Medications into One Syringe
III.C.3.b.4.g
VI.A.1.a.4.m
Load a Cartridge or Injector Device
III.C.3.b.4.g
VI.A.1.a.4.m
Administer an Intradermal Injection
III.C.3.b.4.g
VI.A.1.a.4.m
Administer a Subcutaneous Injection
III.C.3.b.4.g
VI.A.1.a.4.m
Administer an Intramuscular Injection
III.C.3.b.4.g
VI.A.1.a.4.m
Administer a Z-Track Medication
III.C.3.b.4.g
VI.A.1.a.4.m
subcutaneous taut thrombosis trocar vial viscosity wheal
Developmental Objectives After completing this chapter, you should be able to: 1. Correctly spell and define the essential terms. 2. List six separate routes used for delivering parenteral medications. 3. List four common parenteral routes by injection and list which ones are routinely performed by the medical assistant. 4. Name and describe the components of a hypodermic needle and syringe. 5. Describe various designs of needle safety devices, and discuss the importance of using these devices. 6. Describe the importance of needle safety when administering injections. 7. Describe factors that help determine the size of the syringe, the length of needle, and the gauge of needle to be used. 8. List complications that may occur when incorrect equipment is used or the medication is administered using the wrong route. 9. Describe the role of the medical assistant in the administration of intravenous medications. 10. List several complications that may occur when administering IV medications. 11. List instances in which IV therapy should be discontinued.
Introduction Medical assistants are often responsible for the administration of parenteral medications. The most common form of parenteral medication is injectables. In order to successfully perform this task, the medical assistant must be able to select the appropriate equipment, properly prepare the medication, select a suitable site, and administer the medication using the correct technique. Both providers and patients want to know that they can depend on the medical assistant to institute
A D M I N I S T R AT IO N OF PA R E N T E R A L M E D I C AT IO N S
safety checks along the way to ensure that the entire procedure is performed with absolute accuracy. Failure to institute safety measures can result in serious consequences for the patient and possible litigation for the office. This chapter will address the many duties associated with parenteral drug administration and provide useful tips that will aid in decreasing patient discomfort and anxiety.
ADMINISTRATION OF PARENTERAL MEDICATIONS The term parenteral means pertaining to outside the intestines. When referring to parenteral medication, it means to deliver medication via a route other than through the digestive tract. The most common route used to deliver parenteral medications is through injection; however, other parenteral routes include intravenous (within the vein), transdermal (through the skin), transmucosal (through the mucus membrane), topical (on the skin), and inhalation (through the respiratory tract). This chapter addresses parenteral medications delivered through the injection and intravenous routes; refer to Chapter 32 for all enteral and parenteral routes. Common parenteral routes by injection include intradermal, subcutaneous, intramuscular, and intra-
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articular. Of those routes, only three are routinely used by the medical assistant: intradermal, subcutaneous, and intramuscular. Some medical assistants are also responsible for administering intravenous medications; however, this will vary according to the state’s medical practice act and office policy. Parenteral medications are delivered into the blood stream much more rapidly than oral medications, usually within minutes. The following list provides information regarding the amount of time it takes for a medication to enter the bloodstream through selected parenteral routes: ❖ Intravenous: Instantly to seconds ❖ Intramuscular: 5 to 15 minutes, depending on the drug ❖ Subcutaneous: Several minutes Table 34-1 lists both the advantages and disadvantages of parenteral administration.
Parenteral Equipment and Supplies There is a multitude of equipment and supplies available for the delivery of parenteral medications. Syringes and needles come in many sizes and are selected according to the route the medication is to be given, the patient’s body size, the viscosity (or thickness) of the medication, and the amount of medication to be given.
TABLE 34-1 Advantages and Disadvantages of the Parenteral Route of Administration ADVANTAGES
DISADVANTAGES
Effective route when other routes would be difficult to use. For example, if the patient is unconscious or unresponsive.
Unsanitary equipment or mishandling of the equipment could cause microorganisms to be introduced into the patient.
Medications administered by injection do not cause irritation to the patient’s digestive system, nor are they altered by gastric acids.
An allergic reaction to a parenteral drug may occur more rapidly and may be more severe than an allergic reaction to an oral medication because of how quickly it is absorbed into the bloodstream and the amount that is given in one dose.
An exact dose can be administered to a direct site by injection.
Improper injection procedures could cause damage to the patient’s nerves, tissue, veins, and other vessels.
Effects of the medication take place much more rapidly than the oral route, so a patient that is in excessive pain would receive faster relief from a parenteral pain reliever than an oral pain reliever.
Veins could be traumatized by an intravenous injection.
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Syringes Syringes (Figure 34-1) used today are primarily made of plastic and are completely disposable. Typical syringe sizes range from 1 mL to 5 mL. Larger syringes (10 to 60 mL) are used for irrigating wounds or body cavities, drawing large amounts of blood, and for aspirating fluid from a patient’s joint or body cavity. Syringe selection is primarily based on the amount of medication to be administered. Syringes are packaged in hard plastic containers or peel-apart packages and are sealed to ensure sterility. If a syringe package appears to have already been opened, the syringe should not be used and should be disposed of properly. The components of a syringe include the calibrated barrel, plunger, flange, and tip (Figure 34-2). Table 34-2 explains each component of a syringe.
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FI E L D S M A R T S In order to prevent the medication from becoming contaminated, you must never touch the inside of the barrel of the syringe, the rubber stopper on the plunger, or the tip of the syringe that connects to the needle.
FIGURE 34-2 The parts of a syringe Luer-Lok tip
Needles Needles are available in various sizes and lengths and come in disposable and nondisposable forms. Needle selection is determined by the type of medication to be administered, the route of administration, and the size of the patient. Disposable needles are more commonly used and are prepackaged in sterile plastic or paper wrappers. A needle’s gauge (G) refers to the diameter of the needle. Gauge selection is determined by the viscosity or thickness of the medication. Gauge sizes that are typically used in ambulatory care range from 20 to 27 G. The larger the gauge, the smaller the diameter of the needle (for example, a 22-G needle would be smaller in diameter than a 20-G needle). Figure 34-3 shows the different needle gauges and lengths available.
FIGURE 34-1 Syringes can range from 1 mL to 60 mL. 60 mL syringe 30 mL syringe 10 mL syringe 5 mL syringe
3 mL syringe Tuberculin Insulin syringe with needle
Barrel
Tip Rubber stopper
Rubber stopper
Plunger Plunger
Flange
Flange 3 mL syringe separated 5 mL syringe separated and together
FIGURE 34-3 Examples of different needle gauges and lengths
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TABLE 34-2 Description of the Components of a Syringe Barrel
The cylinder that holds the medication and contains calibrations for precise measuring. The barrel is typically calibrated in milliliters (mL) or cubic centimeters (cc) but may be also be calibrated in minims (M). Some specialty syringes contain other calibrations such as the insulin syringe, which is calibrated in Units.
Plunger
A plastic rod with a rubber stopper on one end that seals the medication within the syringe and flared edges on the other end for maneuvering the plunger. This apparatus either draws medication in or pushes medication out of the barrel.
Flange
The flared plastic rim on the syringe used for guiding the plunger.
Tip
The part of the syringe in which the needle is attached. Different types of syringe tips include: the Slip-tip (Figure 34-4), a smooth tip in which the needle is attached just by slipping it onto the syringe; and the Luer-Lok tip (Figure 34-5), which has a threaded end in which the needle can be locked by twisting. The tip of the syringe must remain sterile throughout the entire procedure.
Table 34-3 provides specific details for selecting the appropriate gauge based on the route and the viscosity of the medication. Note: General guidelines for needle gauges are provided later in the chapter under Routes of Administration and should be used as guidelines for certification and registration testing. The length of the needle is determined by the route of administration, the site of the injection, and the amount of adipose tissue over the injection site. Intramuscular (IM) injections will require a longer needle
FIGURE 34-4 Slip-tip
FIGURE 34-5 Luer-Lok tip
than a subcutaneous or intradermal injection because muscles are deeper than the other two types of tissue. The location of the injection also plays a role in the selection of needle length. The deltoid and gluteal muscles are two common muscles that are used for intramuscular injections, but each muscle is a different size and at a different depth. The deltoid is smaller and more superficial than the gluteal muscle and, therefore, would take a shorter needle. Finally, the amount of adipose tissue that the patient has in the area in which
TABLE 34-3 Common Gauge Sizes Based upon the Route of Administration and Viscosity of the Medication GAUGE OF NEEDLE
VISCOSITY OF MEDICATION
ROUTE
EXAMPLES
19–20
Thicker or oil-based medications
IM
Hormones, steroids, penicillin, and certain vitamin preparations
21–23
Aqueous- or water-based medications
IM
Immunizations and other water-based medications
23–25
Aqueous-based medications
Sub-Q
Immunizations, allergy medications, etc.
26–27
Aqueous-based medications
ID
Allergy testing extracts and PPD extract
30 (usually ultra-fine point)
Aqueous-based medications
Sub-Q
Used when repeated injections are given, such as insulin
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the injection is being administered will also play a role in the length of the needle that is used. Patients with larger amounts of adipose tissue will require a longer needle to penetrate through the extra layers than patients with little adipose tissue. Table 34-4 provides common needle lengths based upon the route of administration, the location of the injection, and the size of the patient. Note: General guidelines for needle lengths are provided later in the chapter under Routes of Administration and should be used as guidelines for certification and registration testing. Parts of the Needle Even though needles come in disposable and nondisposable forms, they all have similar components. Figure 34-6 shows different needles that are used for various routes and Figure 34-7 shows the different parts of a needle.
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FI E L D S M A R T S Many practices stock a limited variety of needle gauges and lengths. This can be a real problem when the patient does not meet the parameters of what is considered to be average. The smart medical assistant will stock a wide variety of needle gauges and lengths to accommodate patients of all sizes and medications of all viscosities.
The parts of a needle include the following: ❖ Point: The sharpened end of the needle, cut in a slanted edge called the bevel
TABLE 34-4 Common Needle Lengths Based upon the Route of Administration, Location of the Injection, and Size of the Patient (Adult Chart) INTRADERMAL INJECTIONS 3
⁄8⬙ to 1⁄2⬙
Patients with little adipose tissue (muscular patients)
3
⁄8⬙ to 1⁄2⬙
Patients with an average to large amount of adipose tissue
1
⁄2⬙ to 5⁄8⬙
5
⁄8⬙
Patients of all sizes SUBCUTANEOUS INJECTIONS
INTRAMUSCULAR INJECTIONS Deltoid: Adult with an underdeveloped or atrophied deltoid muscle and very little adipose tissue (i.e., frail adult) Deltoid: Adult with a well-developed deltoid muscle and an average amount of adipose tissue
1⬙
Deltoid: Adult with a well-developed deltoid and a large amount of adipose tissue
11⁄4⬙
Gluteal: Adult with very little adipose tissue
11⁄4⬙ to 11⁄2⬙
Gluteal: Adult with an average amount of adipose tissue
11⁄2⬙
Gluteal: Adult with a large amount of adipose tissue
2⬙ to 3⬙
Vastus lateralis (thigh): Adult with very little adipose tissue
1⬙
Vastus lateralis (thigh): Adult with an average amount of adipose tissue
11⁄4⬙
Vastus lateralis (thigh): Adult with a large amount of adipose tissue
11⁄2⬙ to 2⬙
Little adipose tissue: Can only pull up very little adipose tissue when lightly pinching the skin in the area in which you are administering the injection (females or males less than 130 lb). Average amount of adipose tissue: Can pull up an average amount of adipose tissue when lightly pinching the skin in the area in which you are administering the injection (females 130 to 200 lb or males 130 to 260 lb). Large amount of adipose tissue: Can pull up a large amount of adipose tissue when lightly pinching the skin in the area in which you are administering the injection (females 200+ lb or males 260+ lb).
A D M I N I S T R AT IO N OF PA R E N T E R A L M E D I C AT IO N S
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Intramuscular
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Subcutaneous
CR ITI C A L TH I N K I N G C H AL LEN G E An elderly, frail patient comes into the practice to obtain a flu vaccine, which is an aqueous or water-based solution. The patient’s deltoid muscle is not very prominent and the patient has very little fat over the deltoid. The needles available are 23 G 5⁄8⬙, 22 G 1⬙, and 20 G 11⁄2⬙. 1. What needle would work best for this particular medication and patient? Give the reason for your selection.
❖
Intradermal
Intracatheters for intravenous use
Butterfly needle and tubing for infusions of medications i.v. over a period of time
FIGURE 34-6 Different needles used for various routes of administration
TOOL BOX Lumen
CR ITI C A L TH I N K I N G C H AL LEN G E Mrs. Sims in room 2 is waiting for an ACTH injection. ACTH is a very thick, oily hormone. Mrs. Sims has a large amount of adipose tissue around her hips and buttocks region and weighs 253 pounds. The needle sizes available include 27 G 3⁄ ⬙, 25 G 5⁄ ⬙, 22 G 1⬙, 21 G 11⁄ ⬙, and 20 G 2⬙. 8 8 2 1. Which needle would work best under these conditions? List your reasons.
❖ Lumen: The bore of a hollow needle ❖ Bevel: The flat, slanted edge of the needle that helps to ease the insertion of the needle into the tissue; there are finer cuts and different lengths of bevels, such as a fine tip bevel, which is used for insulin syringe needles. The finer the cut of the bevel, the less pain felt by the patient and the less trauma to the patient’s tissue. ❖ Shaft: The hollow steel tube of the needle through which the medication passes into the patient ❖ Hub: The component that facilitates the attachment of the needle to the syringe; the hub is color-coded for easy recognition of the size and must remain sterile when assembling the needle and syringe. ❖ Safety device: A mechanism to shield the needle after use (see Figure 34-8)
Point
Shaft
Bevel
Plastic sheath
Point
Shaft
Lumen
Hub Hilt
FIGURE 34-7 The parts of a needle
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FI E L D S M A R T S Even though most injection equipment looks very similar, you should refrain from mixing one manufacturer’s equipment with another manufacturer’s equipment. There may be slight variations in the equipment’s locking mechanisms, preventing the needle from firmly attaching to the syringe. This may cause leakage of medication from the syringe and detachment of the needle during the procedure.
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Needle Safety when Using Parenteral Equipment Needle safety is very important when working with parenteral equipment. Each office should use safety devices to help prevent accidental needlesticks from contaminated needles. There are a variety of different types of safety devices, including retractable needles and plastic sheaths that slide down over the needle. Figure 34-8 shows a couple of different types of safety devices. If a dirty needlestick occurs while performing an injection, the medical assistant should wash the area immediately with soap and water and report the incident to a supervisor. An incident report should be completed and the employee should receive counseling regarding what lab testing should be performed and possible treatment options. Refer to Chapter 10 for a review of needle safety guidelines and procedures to follow in the event of a needlestick.
Preparing Medications Medications for parenteral administration are stored in a variety of different containers. Medications may be stored in a(n): ❖ Ampule (Figure 34-9a): A glass container with a stem that holds a single dose of medication ❖ Cartridge unit (Figure 34-9b): A disposable, prefilled, single-dose cartridge of medication that slips into a nondisposable injection device ❖ Vial (Figure 34-9c): A glass or plastic container that may contain either a single dose or multiple doses of medication
(a)
(b)
(c)
FIGURE 34-9 Various medication containers: (a) ampule; (b) cartridge unit; (c) vial
Measuring Medication in a Syringe The type of syringe used will be based on the amount of medication to be administered and sometimes on the type of medication (for example, insulin). Syringe sizes 3 cc and below are normally calibrated using two scales: minims and milliliters (mL). Larger syringes are normally calibrated in mL only. To draw up the correct amount of medication, the medical assistant must be able to properly read the calibrations on the outside of the syringe. The shorter lines on a 1-cc tuberculin
FIGURE 34-8 Examples of safety needles that assist in preventing accidental needlesticks (Courtesy and © Becton, Dickinson, and Company.)
A D M I N I S T R AT IO N OF PA R E N T E R A L M E D I C AT IO N S
syringe are measured in increments of hundredths. Each small line represents 0.01 cc, or 1⁄100 of a cubic centimeter. The longer lines are measured in tenths— each line represents 0.1 cc, or 1⁄10 of a cc, and range from 0.1 to 1.0 cc. On a 3-cc syringe, the smaller calibrations are measured in tenths and represent 0.1, or 1 ⁄10 of a cc. The larger lines represent increments of 1⁄2, 1, 11⁄2, 2, 21⁄2, and 3 cc. On a 5-cc syringe, the smaller calibrations are measured on a scale of 0.2, or 2⁄10 of a cc, with the longer calibration lines representing 1, 2, 3, 4, and 5 cc. Some specialty syringes are measured in units. A unit is the amount of a substance necessary to stimulate a biological effect. The biological effect that one unit of medication has upon body tissue is decided upon by the International Conference for the Unification of Formulas. Unit increments are commonly used for substances such as insulin and particular vitamins and are specific to the individual substance or medication being administered; therefore, insulin syringes may not be interchanged with other types of syringes. To correctly fill a syringe, the plunger should be pulled back so that the top of the rubber stopper is even with the calibration line on the outside of the syringe, matching the amount of medication ordered by the physician (Figure 34-10).
Withdrawing Medication from a Vial When medication is stored in a vial, it may be in a singledose vial (containing an individual dose of medication) or a multiple-dose vial (containing several doses). The FIGURE 34-10 Examples of syringes containing specific amounts of medication: (a) 3 mL syringe filled to 1.5 mL; (b) standard U-100 insulin syringe filled with 70 U of U-100 insulin; (c) 1 mL syringe filled to 0.3 mL
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name and strength of the drug should be checked on the medication label a minimum of three times and verified with the physician’s order. Always check the expiration date on the vial as well. This information is usually checked: ❖ When removing the medication vial from the shelf ❖ Right before preparing the medication ❖ Right after preparing the medication A vial is packaged with a sterile cap that protects the rubber stopper. The sterile cap will need to be removed in a manner that prevents the stopper from becoming contaminated prior to removal of the medication. Care must also be taken not to contaminate or damage the vial when preparing the medication. Medication in a vial must be aspirated, or pulled into the syringe through a needle, by pulling back on the plunger of the syringe. To prepare the syringe for use, remove it from the wrapper and assemble the needle. Pull the plunger
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FI E L D S M A R T S Always inspect the rubber stopper of the vial to make certain that the rubber is completely intact. Check the medication in the vial to make sure the there is no precipitate (pieces of solid material or crystals) or unusual cloudiness. If anything unusual does appear, do not use the medication and check with a supervisor to see if it should be discarded. Always check to see how the medication should be stored, both before and after opening.
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FI E L D S M A R T S
(b)
There is no need to clean the stopper on a medication vial immediately after removing the seal. The stopper is sterile at this point unless you contaminate it when removing the seal. Once the first dose of medication has been removed, the stopper is no longer considered sterile and will need to be cleansed with an alcohol wipe with each subsequent use.
(c)
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within the barrel back to the calibration line that matches the amount of medication to be removed. For example, if removing 11⁄2 mL of medication from the vial, 11⁄2 mL of air must be inserted into the vial before withdrawing the medication. There is an air pressure vacuum inside the vial that makes it easier to pull up the medication. The purpose of forcing air into the vial is to equalize the pressure within the vial after the medication has been removed. If the proper amount of air is not inserted within the vial, the pressure within the vial will drop, making it very difficult to pull back on the plunger when filling subsequent syringes. On the other hand, if too much air is inserted within the vial, the pressure within the vial will become very powerful, causing the medication to be involuntarily forced out through the stopper and out into the syringe. Once the vial is prepared and the plunger is pulled back to the amount of medication being withdrawn, insert the needle into the vial. With the vial still in an upright position, push the plunger forward to expel the air within the syringe into the vial (Figure 34-11). Pick up the vial and invert it with the needle in it. Make certain that the needle is below the liquid line before pulling back on the plunger (Figure 34-12).
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C R I T I C A L T H I N K I NG CHALLENGE When withdrawing medication from a vial, you notice that it is very difficult to pull back on the plunger. 1. What may be the cause of this problem? 2. What can you do to correct the problem?
Carefully pull back on the plunger until reaching the desired amount of medication to be withdrawn. Gently pull the needle out of the vial and carefully place the cap on the needle following institutional policy. (Tiny air bubbles in the syringe may need to be removed by gently flicking the syringe prior to withdrawing the needle from the vial.) Procedure 34-1 lists the proper steps for performing this procedure.
Withdrawing Medication from an Ampule An ampule is made of sterile glass and contains one single dose of medication premeasured to the exact volume or amount needed. Examples of single-dose medications contained in an ampule include heparin
FIGURE 34-11 Expel an amount of air into the vial that is equal to amount of medication to be withdrawn. FIGURE 34-12 The needle must be below the liquid line in the vial before withdrawing the medication.
A D M I N I S T R AT IO N OF PA R E N T E R A L M E D I C AT IO N S
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F IEL D S M A R T S It is not against OSHA policy to recap a sterile needle. The Needle Stick Safety and Prevention Act is in reference to contaminated needles, not sterile needles.
and morphine. The neck of the ampule is constricted and may cause medication to become trapped at the top of the ampule (Figure 34-13). By flicking the ampule with your wrist and hand, any trapped medication in the top will be forced down into the body of the ampule. The outer surface of the ampule should be cleaned with an alcohol pad or other antiseptic prior to opening. The glass ampule is hermetically sealed, meaning the dose is completely enclosed in glass, and the neck is scored (indented), so it will break easily when opened. The medical assistant should practice safety procedures when separating the neck of the ampule from the body of the ampule by covering the neck with a gauze square and breaking it away from the body (Figure 34-14). This will help prevent tiny particles of glass from flying into the face or eyes of the person pre-
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paring the medication. The neck of the ampule should be placed in a sharps container. A special needle that contains a small filter within the lumen can be used to remove any glass particles that may have mixed with the medication when the top was snapped from the body of the ampule. A membrane filter (Figure 34-15) may also be attached to the syringe before attaching the needle to keep glass out of the syringe. The filter needle is then removed and replaced with a hypodermic needle before injecting the patient. Refer to Procedure 34-2 for the proper steps to follow when withdrawing medication from an ampule. FIGURE 34-14 Cover the neck of the ampule with gauze and snap the neck off away from you.
FIGURE 34-13 Force medication from the neck of the ampule by a quick snap of the wrist.
FIGURE 34-15 Various membrane filters that can be attached to syringes of all sizes, in place of using a standard filter needle
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Reconstituting Medications for Injection Certain medications are packaged in powdered (dry) form and must be reconstituted with a liquid in order to be injected. Powder forms of medication have a longer shelf life than liquid forms. A diluent (liquid) is used to reconstitute the powder. Normally this solution is sterile saline (NaCl), sterile water (H2O), or lidocaine. The diluent may be supplied with the medication or may need to be drawn up separately. The medical assistant must always follow the manufacturer’s instructions when reconstituting a medication. Once the diluent is removed from its original container, it is injected into the powdered drug vial and gently mixed by rolling the solution between both hands until the all of the powder particles are dissolved. Once the particles are completely dissolved, the medical assistant will draw up the freshly made dilution (medication) following the physician’s orders. Procedure 34-3 provides detailed instructions on the steps required for reconstituting powdered drugs.
Mixing Two Medications in a Single Syringe When a physician orders two medications, it is sometimes possible to combine the two drugs into one syringe, thus making it possible to give one injection instead of two separate injections. It is most important to check with the physician or pharmacist to clarify if the two medications can be combined. Some medications are not compatible and may cause problems if combined. When combining two medications, the medical assistant must determine which medication is the
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primary drug and which is the secondary drug. The primary drug is the first drug to be drawn up into the syringe. When administering insulin, the primary drug is the clear insulin and the secondary drug is the cloudier insulin. Always check with the physician when in doubt. Procedure 34-4 lists step-by-step instructions for mixing two medications in a single syringe.
Using a Medication Cartridge or an Injector Device Some medications come in sealed, prefilled glass cartridges that hold a single dose of medication. DepoProvera, penicillin G benzathine, Phenergan, and interferon are examples of medications that are available in cartridges. The prefilled cartridge–needle units require no mixing, no special calculations, and are easily administered to the patient. The cartridge–needle units are designed to fit into a cartridge unit syringe, referred to as an injector device (Figure 34-16). Injector devices, such as Tubex® and Carpuject® syringes, are usually nondisposable, made of nonchrome-plated brass or plastic, and are interchangeable with many brands of cartridges. Procedure 34-5 lists steps that are performed when using a cartridge injector device.
General Guidelines for Parenteral Medications In most medical facilities, the medication is prepared in a different room than the examination room and transferred to the exam room prior to injecting. Below are guidelines to follow when preparing and administering all types of injections:
FIGURE 34-16 A cartridge–needle unit and a reusable injector device
F IEL D S M A R T S Changing the needle between the vial and patient reduces complications during and following the injection. Each time the needle is pushed through the stopper of a vial, it becomes dulled, making it difficult to puncture the skin and creating more pain for the patient. In addition, irritating substances such as allergy extracts may adhere to the needle upon aspiration from the vial. As the needle penetrates the skin, a small amount of the medication may adhere to the outside of the skin, promoting a painful local reaction at the site of the injection.
Plunger rod
Plunger Rubber collar
Disposable sterile cartridge-needle unit
A D M I N I S T R AT IO N OF PA R E N T E R A L M E D I C AT IO N S
❖ Prepare only one order of medication at a time and for one patient at a time. If the patient is to be given multiple injections, prepare each one separately and label syringes or syringe wrappers with a marking pen so that you can identify which syringe holds what medication. ❖ Follow standard safety precautions when dealing with needles and syringes. ❖ Ensure that contamination does not occur to the equipment during preparation or transport. ❖ Never allow another health care worker to prepare a medication that you will administer, nor should you prepare a medication for someone else. The responsibility for a medication error falls on the person who administers the medication. ❖ Follow the seven rights (from Chapter 32) when administering all medications. ❖ Use two patient identifiers before administering any medications (part of the Patient Safety Act). ❖ Check the patient’s drug allergy status, latex allergy status, and adhesive allergy status prior to administering any medication. ❖ Wash your hands and wear gloves just prior to administering any parenteral medications. The gloves are to protect you against possible bleeding from the site. ❖ Never allow a patient to stand while receiving an injection. The patient’s blood pressure may drop and the patient may faint. ❖ Sites should be free of scar tissue, wounds, lesions, rashes, moles, or any other disturbance in tissue growth. ❖ Cleanse all sites with an approved skin antiseptic using a circular motion prior to the injection. ❖ Stabilize your hand when holding the needle and syringe. Hand movement may cause the needle to move, nicking a blood vessel or nearby nerve. ❖ Follow the same track coming out of a site that you use going in. This will decrease injury to the surrounding tissue.
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❖ Engage the needle sheath or safety device on the syringe immediately following the injection and dispose of the unit in the sharps container. ❖ Patients should wait a minimum of 20 to 30 minutes following the injection to monitor for anaphylaxis.
Guidelines for Aspiration When administering intramuscular and subcutaneous injections, the medical assistant should aspirate to make certain that the needle is not in a blood vessel. Depositing drugs directly into the bloodstream that are meant for slower absorption may result in serious complications to the patient. To aspirate, pull back slightly on the plunger and look for blood in the tip of the syringe. If this occurs, the needle–syringe unit must be removed and disposed of according to OSHA guidelines. Some drug manufacturers discourage aspiration when administering certain types of medications. Medical assistants should check the drug package insert when in doubt. Table 34-5 lists general guidelines for aspiration.
Guidelines for Massaging the Site Following the Injection At the conclusion of subcutaneous and intramuscular injections, gently massage the site with a cotton ball or gauze pad to assist with the disbursement of the medication. Massaging is contraindicated with particular types of medications, especially those that may be irritating to the tissue or those that can stain the skin. Examples of medications in which massage is contraindicated include heparin, imferon, insulin, Fragmin, and Lovenox. Massaging after these injections can damage tissue at the site or cause the medication to be absorbed incorrectly. Massaging is contraindicated when performing all intradermal injections due to the disbursement of the extract into deeper tissue and when administering all Z-track injections.
TABLE 34-5 General Guidelines for Aspiration Intradermal
Do not aspirate on any intradermal injections.
Subcutaneous
General guidelines call for aspiration during subcutaneous injections; however, some medications given through this route discourage aspiration, including Heparin, Lovonox, and insulin. Always check the manufacturer’s insert for clarification.
Intramuscular (IM)
General guidelines call for aspiration for IM injections; however, always check the drug package insert for clarification.
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Following the Procedure Patients should be monitored for anaphylaxis (lifethreatening allergic reaction) for 20 to 30 minutes following the injection. Most anaphylactic reactions will occur during this time period. Check the patient at the end of the monitoring period to make certain there are no concerns. Observe the site where the injection was administered and look for any local reactions including redness, wheals, or swelling. Ask if the patient is experiencing any breathing difficulties or any other unusual symptoms. If the patient experiences anything out of the ordinary, check with the provider before dismissing the patient. Provide the patient with education on how to manage the injection site and what to expect
FIGURE 34-17 An example of a hospital medication log used to document all medications for a specific patient
over the next few days. Document the procedure and the follow-up observations in the patient’s chart. Refer to Chapter 4 for a complete procedure on documenting medications. Medications such as immunizations and narcotics should also be documented in designated log. Figure 34-17 shows a hospital medication log.
ROUTES OF ADMINISTRATION The route that is selected for parenteral delivery will be primarily based on the manufacturer’s recommendation and the intended use of the drug. Routes selected by the manufacturer are based on absorption properties of the drug and possible irritants or dyes in the drug
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F IEL D S M A R T S Patients will often tell you that they do not have to wait following an injection because they are not allergic to the medication. Remind patients that they can develop an allergy at any time and that office protocol requires the patient to wait. Patients refusing to wait should sign a refusal form that states the possible consequences of not waiting. Place the refusal form in the patient’s chart and document the refusal on the progress note. Know your office’s protocol in the event a patient does have a reaction. EpiPens or epinephrine should be stocked in any room where injections are administered.
that may make it harmful to surrounding tissue. Altering any drug routes could cause harmful side effects for the patient, such as tissue abscess and degeneration, tissue staining, and shock.
Intradermal Injections The term intradermal means pertaining to within the skin. The epidermis (outer layer of the skin) is the layer of skin that is used for intradermal injections. In order for the needle to stay within this layer, the needle should be positioned at a 10° to 15° angle (Figure 34-18).
FIGURE 34-18 The needle is inserted at a 10° to 15° angle for an intradermal injection.
When the medication is slowly injected at this angle, a bubble of fluid called a wheal (Figure 34-19) should appear on the outer surface of the skin. The standard sites used for intradermal injections are the inner lower forearm and the middle of the back (Figure 34-20). These sites are used due to the lack of hair found in these areas and the thinness of the skin. Because of the location of the injection, aspiration is not necessary when performing intradermal injections. Common types of injections administered through this route include allergy extract for testing purposes and the PPD or tuberculin skin test. Intradermal injec-
FIGURE 34-19 A wheal should appear on the surface of the arm following an intradermal injection.
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E M R A P P L I C AT I O N Many EMR software applications have a “Logs” section integrated within the software. Medication logs can be easily accessed by clicking on the “Logs” icon or equivalent name and clicking on the appropriate medication log. Often, the manufacturer’s name, lot number, and expiration date will automatically appear from the previous entry. Make certain that these items match the current medication label. If they do not, change these items to match the current label.
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FIGURE 34-20 Sites for an intradermal injection include the inner forearm and the upper portion of the back.
tions should never be massaged because it will force the liquid to be dispersed in deeper tissues, causing the wheal to disappear. Patients receiving intradermal injections will need to have the site evaluated within a prescribed time frame. The provider will measure the site where the wheal was induced. If the wheal extends over a specific parameter, it means that the test is positive. Table 34-6 is a summary chart for key information regarding intradermal injections. Refer to Procedure 34-6 for a complete procedure on administering intradermal injections. Chapter 16 provides additional information on TB skin testing.
Subcutaneous Injections The term subcutaneous is a medical term that means pertaining to under the dermis (or true layer of the skin). Subcutaneous tissue is made up of fatty and connective tissue. When administering a subcutaneous injection, the adipose tissue should be slightly pinched between the finger and thumb to help differentiate the adipose tissue from the muscle. The injection is placed in the fatty tissue of the body, not the muscle. In order to reach this tissue, the medical assistant should position the needle at a 45° angle (Figure 34-21); however, a 90° angle may be appropriate for patients with lots of adipose tissue or when using a shorter needle.
TABLE 34-6 Intradermal Injection Summary Chart NEEDLE SIZE
26–27 G, 3⁄8⬙–5⁄8⬙
SYRINGE SIZE
1 mL
ANGLE OF INSERTION
10°–15°
ASPIRATE
No
COMMON MEDICATIONS OR EXTRACTS GIVEN THIS ROUTE
Allergy extract, TB extract
MAXIMUM AMOUNT OF ML PER LOCATION
0.1 mL
MASSAGE
No
A D M I N I S T R AT IO N OF PA R E N T E R A L M E D I C AT IO N S
Intramuscular 90-degree angle
Subcutaneous 45-degree angle
Intravenous
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Intradermal
25-degree angle
10- to 15degree angle Epidermis Dermis Subcutaneous tissue Muscle
Intramuscular (IM)
Subcutaneous (SC)
Intravenous (IV)
Aspiration is recommended for many medications given subcutaneously, but is contraindicated in a select few. Sites commonly used for this route include the fatty outer portion of the upper arms, the lower abdomen, the middle and lower back, and the thigh region (Figure 34-22). Table 34-7 lists important facts about subcutaneous injections. Refer to Procedure 34-7 for instructions on how to administer subcutaneous injections.
FIGURE 34-21 Angles for injection into the correct layer of skin or muscle
Intradermal (ID)
Intramuscular Injections The term intramuscular (IM) means within the muscle. Intramuscular injections are given with a longer needle and at a steeper angle of 90°. The needle must be long enough to penetrate through the skin and subcutaneous tissues and deep into the muscular tissue; otherwise, the medication will seep into the subcutaneous tissue and may cause a sterile abscess or malabsorption of the medication.
FIGURE 34-22 Common sites for a subcutaneous injection
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TABLE 34-7 Subcutaneous Injection Summary Chart NEEDLE SIZE
23–25 G, 1⁄2⬙–5⁄8⬙
SYRINGE SIZE
1–3 mL (use an insulin syringe when giving insulin)
ANGLE OF INSERTION
45°–90°
ASPIRATE
The majority of drugs given through this route should be aspirated, but aspiration is contraindicated in a select few drugs (refer to Table 34-5).
COMMON MEDICATIONS OR EXTRACTS GIVEN THIS ROUTE
Allergy injections, insulin injections, heparin, Lovonox, MMR vaccine, small pox vaccine, IPV vaccine, VAR vaccine
MAXIMUM AMOUNT OF ML PER LOCATION
1 mL
MASSAGE
Yes, except in a select few medications (read manufacturer’s instructions)
Body areas normally used for intramuscular injection sites are the musculature of the dorsogluteal and ventrogluteal regions, vastus lateralis, and the deltoid. When administering an intramuscular injection, the tissue overlying the muscle should be held taut (a term that means to pull or draw tight) to ascertain that the medicine is deposited into the muscle and not the subcutaneous tissue. Table 34-8 provides facts regarding IM injections. Procedure 34-8 lists specific steps for administering IM injections.
Dorsogluteal The dorsogluteal site is used to administer injections in adults and older children. Viscid or thicker medications or medications greater than 1 mL are usually injected into this muscle. Extreme caution is to be used
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FI E L D S M A R T S Ask the patient to relax the muscle when giving an IM injection. The relaxed muscle will help with absorption of the medication and cause less pain for the patient.
when administering injections in this area to ensure that damage does not occur to underlying structures, bones, vessels, or nerves. When locating the correct site for this injection, first locate the greater trochanter of the femur. Next,
TABLE 34-8 Intramuscular Injection Summary Chart NEEDLE SIZE
20–23 G, 1⬙–3⬙
SYRINGE SIZE
3–6 mL
ANGLE OF INSERTION
90°
ASPIRATE
Yes
COMMON MEDICATIONS OR EXTRACTS GIVEN THIS ROUTE
Most vaccines, analgesics, antibiotics, steroids, hormones
MAXIMUM AMOUNT OF ML PER LOCATION
Deltoid: l mL; large muscles such as the dorsogluteal and vastus lateralis: 3 mL
MASSAGE
Generally: yes; Z-Track: no
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F IEL D S M A R T S
FI E L D S M A R T S
When a physician orders a medication that exceeds the maximum number of mL that the site can hold, inquire about dividing the dose into two even doses and giving it in two different locations. Always check with physician for approval prior to dividing.
To assist with relaxation of the dorsogluteal muscle, place the patient in a prone position with the toes turned inward.
emaciated, thin, or elderly patients due to a lack of sufficient muscle tissue. locate the posterior iliac spine. Draw an imaginary line between these two landmarks. Any place above and outside of the imaginary line (Figure 34-23) is considered acceptable for this site. The danger involved with using this site is the accidental penetration of or damage to the sciatic nerve, the superior gluteal artery or vein, or the iliac crest of the hip. Do not use the dorsogluteal site on infants and use careful consideration with small children and FIGURE 34-23a The dorsogluteal site Iliac crest Gluteus medius muscle Posterior superior iliac spine Gluteus minimus muscle
Greater trochanter of femur Sciatic nerve Gluteus maximus muscle Iliotibial tract
FIGURE 34-23b The landmark for dorsogluteal injections
Ventrogluteal The ventrogluteal muscle can accommodate many of the same medications injected into the dorsogluteal muscle and may be used for patients of all ages. The ventrogluteal area is free of major nerves and vessels so it is considered safer than the dorsogluteal site. To locate the ventrogluteal site, the medical assistant should be positioned to face the lateral side of the patient’s hip. Center the top of the hand or fingers over the patient’s gluteal medial muscle, just below the iliac crest. If facing the patient’s right side, place the left palm over the greater trochanter of the femur, place the index finger of the left hand on the anterior superior iliac spine, and spread the middle finger posteriorly as far as it will reach along the iliac crest. This should create a “V.” Within the “V” is where the injection will be administered (Figure 34-24).
Vastus Lateralis The vastus lateralis is part of the quadriceps group of the thigh and is the preferred site for administering injections on infants and young children. This is because it is larger and more developed than any of the other large muscle groups at birth. The vastus lateralis can also be used to administer IM injections to adults and is relatively free of large vessels and major nerves. Some adults may find it more painful to use this site than the dorsogluteal or ventrogluteal sites. To find the correct location of the vastus lateralis in adults, the
TOOL BOX
FI E L D S M A R T S To assist with relaxing the vastus lateralis, have the patient sit at the edge of the table with legs dangling over the edge of the table.
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Tubercle of iliac crest
Femoral nerve
Gluteus medius muscle Anterior superior iliac spine Gluteus minimus muscle
Anterior superior iliac spine Tensor fasciae latae muscle
Tensor fasciae latae muscle Gluteus maximus muscle
Femoral artery and vein
Greater trochanter of femur
Sartorius muscle
Vastus lateralis muscle
FIGURE 34-24a The ventrogluteal site
Patella
FIGURE 34-25a The adult vastus lateralis site
FIGURE 34-24b The landmark for ventrogluteal injections
medical assistant should position the hand so that it is at least one hand’s width below the proximal end of the greater trochanter of the femur. Place the other hand so that it is at least one hand’s width above the kneecap. The injection may be placed anywhere between those two landmarks along the lateral or outer portion of the thigh (Figure 34-25). Sites for infant and pediatric injections are found in Chapter 19.
Deltoid The deltoid is a smaller muscle than the other intramuscular sites, but can be used for thinner, less viscid medications with a limited volume, such as immunizations. No more than 1 mL of medication should be given in this location. The deltoid is not recommended for infants and small children because the muscle is not yet fully developed. The deltoid can be located by placing two fingers on the acromion process and measuring 1 to 2 inches below it (Figure 34-26). The injection should be administered in the most prominent portion of the muscle.
FIGURE 34-25b The landmark for vastus lateralis injections
TOOL BOX
FI E L D S M A R T S To assist with relaxation of the deltoid muscle, have the patient drop the arm against the side of the body.
A D M I N I S T R AT IO N OF PA R E N T E R A L M E D I C AT IO N S
Acromion Clavicle
Deltoid muscle Brachial artery and vein Cephalic vein Humerus
FIGURE 34-26a The deltoid site
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cutaneous tissue over the dorsogluteal tissue are displaced or pulled laterally before the needle is inserted by placing the palm of the nondominant hand on the surface of skin, and pulling it several inches to the side. This hand should not move until the end of the procedure. The needle is inserted and the syringe is aspirated (one-handed technique) to make certain that the needle is not in a blood vessel. Following aspiration, medication is slowly injected into the tissue. Wait 10 seconds before removing the needle to give the medication time to be absorbed. Immediately remove the hand, holding the tissue to help create a seal (Figure 34-27). The displaced tissue will return to its original shape or location and stop the medication from leaking out into the subcutaneous tissue. The pathway of the needle is interrupted when using this technique and is quite effective in preventing the loss of medication or discoloration of the skin from occurring. Do not massage Z-track injections. Procedure 34-9 provides further details on how to perform this procedure. Common medications given by the Z-track method include iron preparations and medications that are irritating to superficial tissue, such as Vistaril®.
FIGURE 34-27 Remove the hand holding the Z-track immediately after withdrawing the needle.
FIGURE 34-26b The landmark for deltoid injections
TOOL BOX
F IEL D S M A R T S When administering an immunization in the deltoid muscle, use the patient’s dominant arm. Increased muscle use will promote better circulation and will help to work out the soreness from the injection much faster.
Skin pulled taut
Z-Track Method of Injection The Z-track method is used when the medication may cause irritation to the skin or cause discoloration of the tissues. This method seals the medication deeply within the muscle and allows no exit path back into the subcutaneous tissue and skin. The skin and sub-
Skin released
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PARENTERAL COMPLICATIONS To reduce the risks of parenteral complications, follow the guidelines listed throughout the chapter. Table 34-9 lists potential ramifications of performing injections using incorrect techniques.
IMMUNIZATIONS When most people think about immunizations, often they just think about children (refer to Chapter 19 for information about immunizations in children), but
adults receive their fair share of immunizations as well. Immunizations such as the hepatitis B series, DT immunizations, and flu and pneumonia vaccinations are just a few of the common immunizations that are listed on the adult immunization schedule. There have been a few new immunizations introduced in recent years, including the shingles vaccine and the HPV vaccine. It is important to help patients stay up to date with immunizations and provide patients with education about the newest immunizations available and their benefits. Figure 34-28 lists the standard immunizations for adults.
TABLE 34-9 Possible Parenteral Complications INCORRECT TECHNIQUE
CONSEQUENCES
EFFECTS
Failure to change the needle between the vial and patient
Tissue irritation or discoloration Excess pain to the patient
Local reaction to the skin or muscle Discoloration of the skin Increased amount of pain because of the needle’s dullness
Using a needle that is too short
Medication will be deposited into incorrect tissue
Medication will not be absorbed the way the manufacturer intended it to be absorbed, thus changing the desired effects of the medication Abscess Tissue degeneration
Using a needle that is too long
Medication will be deposited into incorrect tissue
Medication will not be absorbed the way the manufacturer intended it to be absorbed, thus changing the desired effects of the medication Could cause damage to the periosteum resulting in infection and bone retardation Needle could break off into the bone
Failing to aspirate on medications that should be aspirated
Deposition of medication directly into a vein or artery
Shock: Medication was not intended to go directly into the bloodstream. May cause patient’s heart to beat faster, respiration rate to increase, blood pressure to drop. Patient may become unconscious.
Break in sterile technique
The introduction of microorganisms into the muscle, subcutaneous tissue, or blood stream
Blood infection An abscess in the subcutaneous tissue, muscle tissue, or surrounding tissue Tissue degeneration
Choosing a muscle that is underdeveloped
May cause injury to the nearby nerves
Tingling Excruciating pain Paralysis
Injecting a patient with a small-gauge needle when administering a viscid solution
May cause injury to the surrounding tissue
Burning Tissue degeneration Increased pain to the patient
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Recommended Adult Immunization Schedule Note: Thes ons must be read with the footnotes that follow.
Figure 1. Recommended adult immunization schedule, by vaccine and age group United States, October 2007 – September 2008 AGE GROUP
VACCINE
19– 49 years
1 dose Td booster every 10 yrs
Tetanus, diphtheria, pertussis (Td/Tdap)1,* Human papillomavirus (HPV)2,* Measles, mumps, rubella (MMR) 3,*
> 65 years
50–64 years
Substitute doseofofTdap Tdapforfor Substitute 11dose TdTd 3 doses females (0, 2, 6 mos)
1 or 2 doses
1 dose
Varicella 4,*
2 doses (0,
In uenza 5,*
4– 8 wks)
1 dose annually
Pneumococcal (polysaccharide) 6,7
1–2 doses
Hepatitis A 8,*
1 dose
2 doses (0,
Hepatitis B 9,*
6–12 mos or 0,
3 doses (0, 1–2,
Meningococcal 10,*
6–18 mos)
4– 6 mos)
1 or more doses
Zoster 11
1 dose
*Covered by the Vaccine Injury Compensation Program.
CS115143
For all persons in this category who meet the age requirements and who lack evidence of immunity (e.g., lack documentation of vaccination or have no evidence of prior infection)
Recommended if some other risk factor is present (e.g., on the basis of medical, occupational, lifestyle, or other indications)
Report all clinically signi cant postvaccination reactions to the Vaccine Adverse Event Reporting System (VAERS). Reporting forms and instructions on ling a VAERS report are available www.vaers.hhs.gov at or by telephone, 800-822-7967. Information on how to le a Vaccine Injury Compensation Program claim is availablewww.hrsa.gov/vaccinecompensation at or by telephone, 800-338-2382. To le a claim for vaccine injury, contact the U.S. Court of Federal Claims, 717 Madison Place, N.W., Washington, D.C. 20005; telephone, 202-357-6400. Additional information about the vaccines in this schedule, extent of available data, and contraindications for vaccination is also available www.cdc.gov/vaccines at or from the CDC-INFO Contact Center at 800-CDC-INFO (800-232-4636) in English and Spanish, 24 hours a day, 7 days a week. Use of trade names and commercial sources is for identi cation only and does not imply endorsement by the U.S. Department of Health and Human Services.
FIGURE 34-28 Recommended adult immunization schedule by vaccine and age group, updated annually and posted on the CDC’s Web site, http://www.cdc.gov.
TOOL BOX
CR ITI C A L TH I N K I N G C H AL LEN G E You are performing a flu vaccine on a very frail senior adult. Upon insertion of the needle, the needle suddenly comes to a stop and you feel like you hit a brick wall. 1. What probably just occurred? 2. How can you correct this? 3. Should you tell the patient what just happened? How about the provider? 4. How could this have been prevented?
Contraindications and Precautions in Vaccine Administrations There are many misconceptions regarding immunizations among the general population. It is important for medical offices to stock brochures that will assist in answering these questions and in helping to calm the fears of patients and parents of pediatric patients about risks involved with immunizing. Some of the more common misconceptions are that immunizations should not be given to women who are pregnant or breastfeeding. The only two vaccines known to actually cause harm to a developing fetus are the MMR and Varicella due to the fact that they are live vaccines. Some of the newer vaccines, such as the HPV vaccine, are still being experimented with to determine if there are risks to the developing fetus.
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Immune-compromised patients should explore the benefits and risks of immunizing and make an informed decision on what is best for their particular situation. Some contraindications to vaccines include the addition of preservatives or stabilizers that may be the cause of allergy sensitivity such as gelatin, eggs, or other types of plant derivatives used in processing the vaccines. Read the package inserts very carefully and screen the patient before administering the immunizing agents to verify prior history of sensitivity or allergic reaction. The CDC has a great deal more information regarding immunization contraindications on their Web site at http://www.cdc.gov.
BASICS OF INTRAVENOUS THERAPY Intravenous (IV) therapy is the administration of fluids or medications directly into a vein. The purpose of administering fluids intravenously may be to replace lost fluids or to introduce medication, solutions, or nutrients to a patient. IV injections are usually administered directly into the vein (bolus) or injected into an access port on the IV line. Intravenous therapy is preferred when the patient requires fast absorption and can bring quick results because fluids enter the bloodstream immediately. IV therapy is drug specific, meaning only certain drugs are administered by this route. It is important to understand the difference between intravenous injections and intravenous infusion. IV injections consist of a relatively small amount of fluid being introduced into the veins, while IV infusion is the process of infusing fluid volumes of 50 mL to 500 mL or more into the body. Laws vary from state to state as to whether medical assistants can perform procedures directly related to intravenous therapy. Health care facilities such as ambulatory care clinics and urgent care centers have started to delegate specific job duties to the medical assistant including gathering the supplies, starting the IV, monitoring the patient for adverse reactions, and discontinuing the IV. A licensed physician is the one who prescribes IV therapy. Whether or not the medical assistant will be able to start IVs will be determined by state law and office policy. The medical assistant must be aware of the laws in the state in which she practices so that the medical assitant does not go beyond the scope of duty.
Equipment and Supplies Employed in Intravenous Therapy Equipment and supplies available for use in IV therapy are continually being updated to com-
ply with federal and state laws regarding safe work practices and for patient comfort. Containers for IV fluids have changed from glass containers to pliable plastic bags (Figure 34-29) that are lightweight and not at risk of becoming broken or damaged. IV fluid bags range in size from 50 to 2000 mL, with the smaller bags often referred to as “piggyback” bags. When prescribed, the pharmacy will open the bag to add additional medications to the fluids and label the bag with the specific prescription the physician has ordered. If a bag is found with the opaque outer bag removed, do not use the solution because sterility and viability of the product may be compromised. The tamper-proof additive caps are removed when additive drugs are mixed within the IV bag. Piggyback containers are used for reduced volume of fluid infusion and are filled with ready-to-use medications at the time of manufacturing. The pharmacy will add additional medications if prescribed, such as antibiotics. Commonly used fluids contained within an IV bag for infusion are normal saline (NaCl) or dextrose in water. Infusions are given to replace lost body fluids, restore fluid balance of cellular tonicity, or to provide medications or nutrients to the body. Homeostasis of FIGURE 34-29 Flexible IV solution containers (Courtesy of Baxter Healthcare Corp.)
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TABLE 34-10 Common Fluids Used for IV Therapy INFUSION
INDICATIONS
5% Dextrose in water (D5W)
Fluid replacement for rehydration
Normal saline (0.9% NaCl)
Used to replace sodium losses
Dextrose in saline solutions
Fluid replacement for burns, rehydration, maintenance infusion, circulatory insufficiency, and in cases of shock
Ringer’s Solution Na 147 mEq/L, K 4 mEq/L, Cl 155 mEq/L
Restores fluid and electrolyte balance, used when patients have lactose intolerance, may be used as a blood replacement for a short time
the body and its functions is the primary reason for infusion of fluids. The fluid choice is based on the electrolyte balance and the patient’s needs at the time. While there are numerous types of fluids used during IV administration, some common products are included in Table 34-10. Infused fluids are introduced to the body through administration sets, which is tubing that connects the IV bags to the IV cannula in the patient. Administration sets come in a variety of styles, from the very basic solution set to multiple administration tubing. All IV tubing sets have common components including clamps, a piercing pin, a drip chamber, and a cannula adapter.
Basic IV Administration Sets
FIGURE 34-30 An IV administration tubing set
FIGURE 34-31 Tubing clamps
Each IV administration set has similar components, including: ❖ Piercing pin (Figure 34-30): A hollow spike that is inserted into the administration port of the IV bag. It is important this remains sterile when inserted. ❖ Drip chamber (Figure 34-30): This is where the solution flows prior to its entry into the tubing; it acts as a pressurizing chamber for non-vented bags. ❖ Roller clamp (Figure 34-31): This is used to regulate the flow of fluids through the IV tubing. ❖ IV cannula or catheter (Figure 34-32): A flexible tube that is used to insert medication within
Piercing pin Open
Flange Drip chamber
Open Close
Drop orifice Close Luer slip Close
Open Close
Open Slide clamp
FIGURE 34-32 A catheter and needle
Flow control clamp
Injection port Protective cap
Catheter hub Catheter Needle
Flashback area
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a body cavity or blood vessel. It has a trocar (a sharp-pointed needle) attached to it that punctures the skin to get the catheter within the vein. ❖ Slide clamp: This is used to restrict fluid flow and act as a quick on/off control of the IV tubing. The tubing ends in a sterile-capped adapter, which is attached to the cannula. Because of the legal issues involved with IV administration, the medical assistant’s responsibilities for IV therapy are usually to collect the equipment and supplies and to assist with taping the IV in place (Figure 34-33). The provider or nurse will usually be responsible for starting the IV. The infusion of fluids can be achieved by either an infusion pump (Figure 34-34) or by gravity flow. The gravity method is controlled by the roller clamps on the IV tubing. The tighter the clamp, the less fluid that flows through the tube. The drip chamber is used in calculating the drops per minute that flow into the IV tubing. The IV pumps are more concise in delivery and more practical and safe for the patient. Constant monitoring
of the IV set for occlusions is not necessary with the IV pumps. The pump will sound an alarm if an occlusion (blockage or closure) is detected or if the timing of the flow rate indicates the bag is almost empty. With the pump, the fluid is forced with light pressure into the veins and lessens reflux, which is the backing up of fluids into the veins and tissues. The pump can be set for different lengths of time and rates of infusion. Some pumps can run multiple IV lines on the same patient.
Documentation of IV Therapy The health care professional that inserts and starts the IV will be responsible for documenting the procedure. Documentation in the patient’s chart should include the IV site location, number of attempts of insertion, any complications of the procedure, the date and time of insertions, the needle gauge and length, and the person’s initials that inserted the catheter. Any adverse reactions to the procedure such as redness, pain, swelling, bruising, and other essential findings that are not problematic at this point but could lead to complications at a later date and time should also be documented.
FIGURE 34-33 Proper taping of an IV site: (a) Place a foam pad under the cannula; (b) apply the dressing; (c) pinch to secure the dressing to tubing; (d) secure with tape; (e) when removing, use alcohol to loosen tape. (Courtesy of ConMed Corp.)
(a)
(d)
(b)
(e)
(c)
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Pressure History Graphically displays pressure trend for last two hours.
Large Backlit Center Display (Scratch Pad) Facilitates programming.
Dual-Channel Delivery Permits simultaneous delivery of two separate infusions at independent rates.
Rapid Rate, On-Line Titration Facilitates rapid rate adjustments without interrupting flow.
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RS-232 Data Port Enables communication with a variety of information and remote monitoring systems. Micro/Macro Infusion Capability Delivers precise infusions at rates from 0.1 to 99.9 mL/hr in 0.1 mL/hr increments and from 1 to 999 mL/hr in 1 mL/hr increments. Pump/Controller Modes Eliminates timeconsuming instrument exchanges (based on hospital infusion protocols). Can switch between pump and controller modes with the press of a single key.
Programmable Start Time Can automatically start multiple infusions at specified times.
All Fluids Air-In-Line Detector Significantly reduces the chance of accidental administration of air.
Multi-Dosing Enables the automatic delivery of a series of infusions, from the same IV container, at specified times.
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Flo-Stop® Device Provides disposablebased protection against accidental IV free-flow.
Dual-Rate Piggybacking Automatically switches to primary parameters upon completion of secondary (piggyback) infusion.
Volume/Time Dosing Automatic calculation of rate by programming volume and time.
Automatic Drug Calculation Calculates drug dose or rate automatically for all standard units of measure.
FIGURE 34-34 An IV infusion pump (Courtesy of Alaris Medical Systems.)
Risks, Complications, and Adverse Reactions of IV Therapy Intravenous therapy can have numerous inherent risks and complications associated with this type of medication administration procedure. The medical assistant must be knowledgeable in recognizing the complications, signs, and symptoms that may arise from the IV infusion. The different complications can be classified as local, systemic, or be a combination of the two. Local complications may consist of pain and irritation at the insertion site, cannula dislodgement, catheter or needle occlusion, and phlebitis (inflammation of the vein). Other complications may involve hematoma
formation, venous spasm, vessel collapse, thrombosis (blood clot), and nerve, tendon, or ligament damage. It is essential to communicate with the patient to assess complications of IV therapy or patient intolerance of the IV catheter. The medical assistant may be the health care professional that monitors the patient for complications and should know when the provider or nurse should be alerted. Table 34-11 explains some questions to ask a patient to clearly define the effectiveness of the therapy and patient tolerance. Once the medical assistant has assessed the patient’s pain, it is important to relay this information to the provider so a determination can be made for the most
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TABLE 34-11 Guideline Questions for Patient Pain Assessment 1. Tell me about the pain you are having. 2. Where does it hurt? 3. When did it start? 4. Is the pain in one spot, or does it radiate to other places? 5. What kind of pain is it? Aching? Gnawing? Burning? Stabbing or piercing? Dull? Throbbing? 6. Are there any other symptoms of discomfort? 7. Rate the pain on a scale of 1 to 10, with 10 being the worst pain.
appropriate intervention. Depending on the findings, the actions may include discontinuation of the therapy, changing position of the extremity, adjusting the flow rate of infusion, re-taping the site, or applying a warm or cool compress. Table 34-12 explains in further detail more of the complications and risks of IV therapy. Systemic complications are much more dangerous and can be life threatening. The medical assistant should become familiar with symptoms that may indicate a systemic reaction. Table 34-13 provides details of systemic complications that may occur during IV infusion therapy. If the medical assistant notices any of the signs below, immediately alert the provider.
Discontinuation of Intravenous Infusion Therapy When the physician determines the patient no longer needs IV infusion, the IV must be discontinued. The first step in discontinuing IV infusion is proper aseptic technique and the application of gloves. Then the IV tubing is clamped off and removed from the adapter or extension set. Take care to not remove the
TABLE 34-12 Complications and Risks of Intravenous Therapy COMPLICATIONS AND RISKS Infiltration or extravasation
DESCRIPTION
SYMPTOMS
Medication fluid leaks from the cannula or from the vein into the tissues surrounding the site.
Redness, severe swelling, hardness at the site, pain, and edema
Catheter and needle displacement
Redness
Occlusion
The cannula becomes blocked and allows blood to back up into the IV tubing.
Blood in IV tubing
Loss of patency (the openness of the vein)
Occurs when the vein wall has been damaged
Blood in IV tubing
Phlebitis (inflammation of the vein wall)
Bacteria can form as a normal immune response due to the death of leukocytes and other tissue cells.
Vein may be hard, red streak along vein, inflammation, and swelling
Thrombosis
Blood clots form, causing slow or stopped infusion.
Slow or stopped infusion Fever and malaise may be present.
Hematoma
Blood infiltrates into the tissues.
Discoloration of the skin, discomfort, and swelling
Cellulitis
A bacterial infection that can spread to surrounding tissues
Redness, red streak at the site of the needle or nearby
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TABLE 34-13 Signs and Symptoms of Systemic Complications SYSTEMS AFFECTED BY SYSTEMIC COMPLICATIONS
SIGNS AND SYMPTOMS
Cardiovascular system
Facial edema, generalized edema, erythema along veins, palpitations, hypotension, cardiac arrest
Gastrointestinal system
Dysphagia, gastric cramping, intestinal cramping, nausea, vomiting
Integumentary system
Flushing, red flare, rash, IV site edema, pruritus (itching), urticaria (hives)
Nervous system
Agitation, anxiety, confusion, disorientation, headache, loss of sensation or numbness, vertigo
Respiratory system
Nasal congestion, runny nose, cough, sensation of tightness in throat, mucous membrane edema, bronchospasm, respiratory arrest
Special senses
Pruritus, watery eyes, scratchy throat, tinnitus (ringing in ears), buzzing sound in ears, tingling or numbness in fingers or toes, vertigo
adapter—this will cause blood to leak profusely out of the cannula hub. Remove the transparent dressing by rubbing the patient’s skin with an alcohol pad, which will loosen the adhesive in the dressing. This helps patients who have a lot of hair on their arm or in cases in which the adhesive dressing has adhered to skin and is difficult to remove. Once the transparent dressing is removed, the tape securing the cannula hub should be removed. Take care not to accidentally dislodge the hub from the site during this process. When the tape is completely removed, prepare a gauze pad and place above the cannula site. Inform the patient to take a deep breath and when the patient breathes in, remove the cannula in one smooth continuous movement without pressing down on the cannula. Place the gauze over the site and apply pressure for five minutes. Be sure to inspect the cannula (Figure 34-35) to make sure it is in one piece and has not broken off within the vein. Document in the patient’s chart the state of the cannula for its “intact” form (for example, “Cannula removed from right anterior forearm. Cannula intact. Patient tolerated procedure well. No swelling, no bruising, or other complications noted.”). Intravenous therapy is a concise procedure and should be performed only by specially trained individuals. If medical assistants are asked to perform duties that exceed their training, life-threatening incidences may occur to the patient. If unsure of what exactly is detailed in the procedure, verify with the ordering physician to ensure complete understanding of the expectations of performance and completion of the administration of
FIGURE 34-35 Inspect the cannula following withdrawal from the patient’s vein.
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intravenous therapy. If medical assistants are allowed to perform IVs in their state but feel uncomfortable performing the procedure, they should get assistance from their superior or the provider.
INTRA-ARTICULAR INJECTIONS The term intra-articular means within a joint. Some injections are given within a joint to help reduce inflammation and pain. Patients that suffer with osteoarthritis are usually good candidates for these types of injections. The knee is the most common joint in which these injections are given but other joints can be injected as well. Steroids to reduce inflammation are the common drug category used to treat osteoarthritis. The medical assistant’s duty for these injections would be to prepare the patient for the injection and to have all of the equipment ready for the physician. The medical assistant may need to help hold the joint still during the injection procedure.
TOOL BOX
C R I T I C A L T H I N K I NG CHALLENGE You work in an urgent care center and the physician instructs you to start an IV on a specified patient. You know that the Medical Practice Act in the state in which you work requires a licensed health care provider or registered nurse to perform this procedure. All of the rest of the medical assistants in the facility start IVs. One of the medical assistants tells you that she will assist you with your first IV. 1. How will you respond to the physician?
PROCEDURE 34-1 Withdraw Medication from a Vial Objective: To prepare medication from a vial for administration.
Equipment/Supplies: ❖ Vial of medication ❖ Antiseptic wipe ❖ Needle and syringe appropriate for procedure
❖ Gauze 2x2 sponges ❖ Sharps container ❖ Medication tray
PROCEDURAL STEPS
RATIONALE
1. Wash your hands and apply gloves.
This prevents the spread of infection and contamination during the procedure.
2. Assemble the equipment. 3. Work in a quiet and well-lit area.
Distractions and poor lighting may lead to medication errors.
4. Select the correct medication from the storage area and check the drug label (Medication Check #1).
This assists in making certain you have the correct medication.
5. Check the expiration date.
Using a medication beyond the expiration date may decrease the effectiveness of the drug.
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PROCEDURAL STEPS
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RATIONALE
6. Compare the medication with the physician’s order (Medication Check #2).
This alleviates the possibility of mistakes and wasting of valuable medication.
7. Calculate the correct dose to be given, if needed. Verify the correct calculations with the physician if necessary.
Giving the correct dose helps to obtain the desired effects and avoid complications.
8. Open the syringe and attach the needle to the syringe. 9. Open the antiseptic wipe and clean the vial stopper (Figure 34-36).
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FIGURE 34-36 This prevents contamination of the vial and the needle when preparing the injection.
10. Holding the syringe at eye level, pull back on the plunger of syringe to draw an amount of air into the syringe equal to the amount of medication to be withdrawn from the vial.
This keeps the pressure in the vial at atmospheric pressure.
11. Check to make sure the needle is firmly attached to the syringe and remove the cap from the needle.
If the needle is not firmly attached to the syringe, it may become disconnected and cause an injury to the person preparing the medication or to the patient during the procedure.
Cleanse the stopper of the vial.
FIGURE 34-37 Insert the needle through the rubber stopper.
12. Insert the needle through the rubber stopper (Figure 34-37) until it reaches the empty space between the stopper and the fluid level. 13. Push forward on the plunger to inject air into the vial. Keep the needle above the fluid level.
Forcing air into the medication can cause the fluid to break down or bubble, thus creating more bubbles in the medication vial.
14. Invert the vial while holding onto the syringe and plunger. Hold the vial and syringe without contaminating the needle or hub of the syringe. These parts of the syringe must remain sterile.
This helps prevent microorganisms from entering the vial and the patient from obtaining an infection.
15. Hold the syringe at eye level and withdraw the proper amount of medication (Figure 34-38).
This ensures that you are reading the calibration lines correctly.
16. Keep the tip of needle below the fluid level.
This prevents air microorganisms from entering the vial and from being drawn into the syringe.
17. Remove any air bubbles in the syringe by tapping or flicking the side of the syringe where the bubbles are located (Figure 34-39).
If there are air bubbles in the syringe, you may not have the correct amount of medication. Air bubbles can take up extra space. Air bubbles may also cause pain to the patient.
FIGURE 34-38 Hold the vial at eye level during withdrawal of the medication.
FIGURE 34-39 Flick the syringe to remove any air bubbles.
continues
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continued
PROCEDURAL STEPS 18. Remove any air remaining in the tip of the syringe. Check to make certain that you still have the correct amount of medication. If you do not, make the appropriate adjustments to ascertain you have the correct amount before removing the needle from the vial.
RATIONALE Removing air bubbles and expelling any air could change the volume of medication in the syringe.
19. Remove the needle from the rubber stopper of the vial. 20. Replace the needle cap on the syringe (Figure 34-40) or replace with a new needle and cap setup.
21. Read the medication label and replace the medication vial in the correct storage cabinet (Medication Check #3).
Replacing the needle unit reduces the risk of a local reaction if the needle used to withdraw the medication is changed between the vial and patient. Pushing the needle through the rubber stopper dulls the needle; a new needle pierces the skin much easier.
FIGURE 34-40 Replace the needle cap.
Three checks help to ensure you have the correct medication and prevents errors from occurring.
22. Place the syringe onto a clean tray with other items necessary for the injection, including an alcohol wipe, a cotton ball, and an adhesive bandage.
PROCEDURE 34-2 Withdraw Medication from an Ampule Objective: To prepare medication from an ampule for administration.
Equipment/Supplies: ❖ Ampule of medication ❖ Antiseptic wipes (2) ❖ Needle and syringe appropriate for procedure ❖ Filter needle
❖ Gauze 2x2 sponges ❖ Sharps container ❖ Medication tray
A D M I N I S T R AT IO N OF PA R E N T E R A L M E D I C AT IO N S
PROCEDURAL STEPS 1. Wash your hands and apply gloves.
❖
RATIONALE This prevents the spread of infection and contamination during the procedure.
2. Assemble the equipment. 3. Work in a quiet and well-lit area.
Distractions and poor lighting may lead to medication errors.
4. Select the correct medication from the storage area and check the drug label (Medication Check #1).
This helps to ascertain you have the correct medication and prevents error from occurring.
5. Check the expiration date.
No medication should be given if the drug has reached the expiration date, as it may not be effective.
6. Compare the medication with the physician’s order (Medication Check #2).
This alleviates the possibility of mistakes and wasting of valuable medication.
7. Calculate the correct dose to be given, if needed.
An incorrect dose could cause great harm to the patient.
8. Open the syringe and filter needle and assemble, if necessary.
A filter needle filters out possible glass fragments that may be present from snapping the stem from the body of the ampule.
9. Tap the stem of the ampule lightly, or snap the wrist of the arm holding the ampule, to remove any medication in the neck of the ampule.
This forces the medication into the base of the ampule container.
10. Open the antiseptic wipe and clean the ampule container. Allow the ampule to dry completely.
This prevents contamination of the needle when preparing the injection.
11. Place a piece of gauze around the neck of the ampule. Hold the ampule firmly between the fingers and the thumbs of both hands.
This protects the fingers when breaking open the neck of the vial.
12. Break off the stem by snapping it quickly and firmly away from the body. Discard the top in a sharps container and carefully set the ampule down on a flat, firm surface.
This keeps glass fragments from flying into the medical assistant’s eyes or face.
13. Check to make sure the filter needle is firmly attached to the syringe and remove the cap from the needle.
If the needle is not firmly attached it may cause injury to the person preparing the medication.
14. Insert the needle into the ampule below the fluid level. Hold the ampule at a slight angle while advancing the needle within the glass body. Completely draw up all the medication into the syringe (Figure 34-41).
Tilting the ampule facilitates emptying the entire ampule.
15. Remove the needle from the ampule without allowing the needle to touch the edges of the ampule.
This prevents contamination of the needle.
16. Dispose of the ampule into the sharps container. Check the medication label before discarding the ampule (Medication Check #3).
Immediately disposing of the ampule prevents injury to the person preparing the medication for injection.
FIGURE 34-41 Hold the ampule at a slight angle when withdrawing medication.
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PROCEDURAL STEPS
RATIONALE
17. Remove any bubbles in the syringe.
This helps to prevent little air bubbles from entering the patient.
18. Pull back slightly on the plunger to draw the medication from the needle into the syringe, engage the safety device, and remove the filter needle.
This removes any medication that remains within the filter needle. Medication cannot be administered to the patient with the filter needle.
19. Open a new needle for administering medication to the patient and attach it correctly to the syringe.
The filter needle may have glass fragments inside, so it is not used.
20. Remove the cap from the needle and push slightly forward on the plunger to remove air that is within the tip of the syringe and shaft of the needle.
This expels any air that is within the syringe tip and shaft of the new needle to ensure that air is not being injected into the patient’s tissues.
21. Replace the needle cap on the syringe following institutional policy. 22. Prepare the medication tray. Place a bandage, a gauze pad or cotton ball, an antiseptic wipe, and the syringe on a medication tray for transporting to the exam room to administer the injection to the patient.
PROCEDURE 34-3 Reconstitute a Powdered-Base Medication with a Diluent Objective: To reconstitute a powdered-base medication for preparation of administering an injection to a patient.
Equipment/Supplies: ❖ ❖ ❖ ❖
Vial of powdered medication Vial of diluent Antiseptic wipe Two needles and a syringe appropriate for procedure
PROCEDURAL STEPS 1. Wash your hands and apply gloves.
❖ Gauze 2x2 sponges ❖ Sharps container ❖ Medication tray
RATIONALE This prevents the spread of infection and contamination during the procedure.
2. Assemble the equipment. 3. Work in a quiet and well-lit area.
Distractions and poor lighting may lead to medication errors.
4. Select the correct medication and diluent from the storage area, and check both drug labels (Medication Check #1).
Having the wrong medication or diluent could cause harm to the patient.
A D M I N I S T R AT IO N OF PA R E N T E R A L M E D I C AT IO N S
PROCEDURAL STEPS
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RATIONALE
5. Check the expiration date on both labels.
Medication should not be given if the drug has reached the expiration date, because it may not be effective.
6. Compare the medication with the physician’s order (Medication Check #2).
This alleviates the possibility of mistakes and wasting of valuable medication.
7. Calculate the correct dose to be given, if needed. Verify the correct calculations with the provider if necessary.
Giving the wrong dose could cause great harm to the patient.
8. Open the syringe and needle and assemble, if necessary. 9. Clean both the powder vial and the reconstituting fluid vial stopper with alcohol before use (Figure 34-42).
This prevents possible contamination to the medication vials or the patient.
10. Pull back on the plunger to fill the syringe with the amount of air equal to the amount of diluting liquid required for reconstitution from the vial containing the diluent.
This equalizes the pressure within the vial.
11. Check to make sure the needle is firmly attached to the syringe and remove the needle cap.
If the needle is not firmly attached to the syringe, it may become disconnected and cause an injury to the person preparing the medication.
FIGURE 34-42 Cleanse the rubber stopper of both vials.
12. Insert the needle into the diluent vial. 13. Push in the plunger, forcing the air from the syringe into the vial of diluent (Figure 34-43).
This equalizes the amount of air in the vial.
14. Invert the vial in the dominant hand, holding it between the thumb and index finger. 15. Keep the needle immersed in the solution while drawing the solution into the barrel of the syringe.
If the needle tip is not inserted in the fluid, air will be drawn into the syringe.
FIGURE 34-43 Inject air into the diluent vial.
16. Check for air bubbles and determine that the exact amount of diluent is withdrawn from the vial before removing the needle from the vial. 17. Carefully remove the needle from the vial. 18. Insert the needle into the vial containing the powdered medication (Figure 34-44). 19. Add the appropriate amount of reconstituting liquid to the powdered drug, slowly rotating vial while injecting fluid into it.
20. Replace the needle cap on the syringe following institutional policy.
This allows the powder to be flushed with the fluids and helps to minimize the formation of clumps within the powder.
FIGURE 34-44 Inject the diluent into powdered medication vial.
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RATIONALE
21. Roll the vial between the hands to thoroughly mix the medication (Figure 34-45).
This allows all of the particles to be suspended appropriately.
22. Record the new date of expiration on the label of the medication vial.
Once the medication has been prepared, it is only good for a certain amount of time.
23. Recheck the medication label before returning the vial to the proper storage area (Medication Check #3).
A third check helps in ascertaining you have the correct medication.
24. Prepare to administer the medication to the patient. Place a bandage, a gauze pad or cotton ball, an antiseptic wipe, and the syringe on a medication tray for transporting to the exam room to administer the injection to the patient.
FIGURE 34-45 Gently roll the vial between the hands to mix well.
PROCEDURE 34-4 Mix Two Medications into One Syringe Objective: To draw two medications into one single syringe for injection administration to a patient.
Equipment/Supplies: ❖ Two vials of medication ❖ Antiseptic wipe ❖ Two needles and a syringe appropriate for procedure
❖ Gauze 2x2 sponges ❖ Medication tray ❖ Sharps container
PROCEDURAL STEPS
RATIONALE
1. Wash your hands and apply gloves.
This prevents the spread of infection and contamination during the procedure.
2. Assemble the equipment. 3. Work in a quiet and well-lit area.
Distractions and poor lighting may lead to medication errors.
4. Select the correct medications from the storage area and check their drug labels (Medication Check #1).
Reading the label helps to acertain you have the correct medication.
5. Check the expiration dates on both vials.
No medication should be given if the drug has reached the expiration date, as the medication may not be as effective.
A D M I N I S T R AT IO N OF PA R E N T E R A L M E D I C AT IO N S
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RATIONALE
6. Compare the medications with the physician’s order (Medication Check #2).
This alleviates the possibility of mistakes and wasting of valuable medication.
7. Calculate the correct doses to be given, if needed. Verify the correct calculations with the provider if necessary.
Giving an incorrect dose could cause great harm to the patient.
8. Open the syringe and needle and remove them from their packaging. Attach the needle to the syringe. 9. Clean the rubber stopper of both vials with an alcohol wipe.
This removes microbes that may be on the stoppers.
10. Determine which medication is the primary medication vial. Do not do anything with the primary medicine at this point.
The primary medication is the first medication to be drawn up.
11. Draw up an amount of air into the syringe that is equal to the amount of medication required from the second vial.
Air is injected into the second vial at this point because once the syringe is filled with medication from the first vial, it will no longer be possible to inject air into the vial.
12. Check to make sure the needle is firmly attached to the syringe and remove the needle cap.
If the needle is not firmly attached it may become detached from the syringe, causing harm to the preparer.
13. Insert the needle into the second vial and push the air from the syringe into the vial to replace the medication that will be taken out later. Do not allow the needle to touch the liquid.
Pushing the needle into the medication will contaminate the needle, affecting the next vial.
14. Carefully remove the needle from the vial. 15. Draw up an amount of air into the syringe that is equal to the amount of medication required to be taken from the primary vial.
This equalizes the pressure due to the fluid being removed from the vial.
16. Insert the needle into the primary vial. Push forward on the plunger, forcing air from the syringe into the primary vial without contacting the medication.
Pushing air into the liquid could create bubbles in the syringe and vial.
17. Invert the vial in the dominant hand, holding it between the thumb and index finger. 18. Keep the needle immersed in the solution while drawing the solution into the barrel of the syringe.
If the needle tip is not inserted in fluid, air will be drawn into the syringe.
19. Remove any air remaining in the tip of the syringe. If there is medication lacking in the syringe, pull back on the plunger so that the correct amount of medication is drawn into the syringe.
This expels any remaining air within the syringe and the needle and ascertains you have the correct amount of medication.
20. Remove the needle from the stopper of the first vial, engage the safety device, and discard into a sharps container. Replace the needle with a new needle.
This reduces the risk of medication from the first vial carrying over to the second vial.
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RATIONALE
21. Smoothly insert the needle into the secondary vial. 22. Invert the vial and slowly withdraw the medication required from the vial. Do not allow any medication from the first vial to be inadvertently injected into the second vial. Pulling slowly to avoid creating air bubbles, pull the plunger back to the correct calibration mark on the syringe.
If medication from the primary vial mixes with the secondary vial it will contaminate the contents of the second vial.
23. Remove the needle from the second vial. 24. Check for air bubbles and remove them from the syringe. 25. Check again that the total amount of medication in the syringe is the correct total to be administered.
If the incorrect dosage is in the syringe, the patient may not obtain the full effects of the medication.
26. Replace the needle cap on the syringe following institutional policy.
Some facilities will allow recapping of clean needles, while other facilities prefer the scoop method.
27. Recheck the medication labels of both vials before returning the vials to the proper storage area (Medication Check #3).
Checking the label three times helps to ascertain you have the correct medication and prevents errors from occurring.
28. Prepare to administer the medication to the patient. Place a bandage, a gauze pad or cotton ball, an antiseptic wipe, and the syringe on a medication tray for transporting to the exam room to administer the injection to the patient.
PROCEDURE 34-5 Load a Cartridge or Injector Device Objective: To prepare medication from a prefilled cartridge for administration.
Equipment/Supplies: ❖ Prefilled cartridge of medication ❖ Cartridge holder ❖ Antiseptic wipe
❖ Gauze 2x2 sponges ❖ Sharps container ❖ Injection tray
A D M I N I S T R AT IO N OF PA R E N T E R A L M E D I C AT IO N S
PROCEDURAL STEPS 1. Wash your hands and apply gloves.
❖
RATIONALE This prevents the spread of infection and contamination during the procedure.
2. Assemble the equipment. 3. Work in a quiet and well-lit area.
Distractions and poor lighting may lead to medication errors.
4. Select the correct medication from the storage area and check the drug label (Medication Check #1).
This ascertains that you have the correct medication.
5. Check the expiration date.
No medication should be given if the drug has reached the expiration date, as it may not be effective.
6. Compare the medication with the physician’s instructions (Medication Check #2).
This alleviates the possibility of mistakes and wasting of valuable medication.
7. Calculate the correct dose to be given, if needed.
There may be instances in which a patient does not need the entire dose within the cartridge.
FIGURE 34-46 Turn the ribbed collar to the open position.
8. Pick up the cartridge unit holder (the injector). 9. Turn the ribbed collar toward the open position until it stops (Figure 34-46).
This allows for the insertion of the cartridge into the holder.
10. Hold the injector with the open end up and fully insert the sterile cartridge–needle unit. 11. Firmly tighten the ribbed collar of the unit at the syringe base by turning the ribbed collar toward the “close” arrow. (Hold the cartridge to prevent it from swiveling inside the holder while tightening.)
FIGURE 34-47
12. Thread the rod of the plunger into the cartridge unit until a slight resistance is felt (Figure 34-47).
If the cartridge is not tightened securely onto the holder, the needle unit may move during the injection procedure.
13. Prepare the medication for injection into the patient at this time. Place a bandage, a gauze pad or cotton ball, an antiseptic wipe, and the syringe on a medication tray for transporting to the exam room. Check the medication label one last time (Medication Check #3).
Checking the label three times ascertains you have the correct medication and prevents errors from occurring.
Thread the plunger onto the cartridge unit.
14. After use, do not recap the needle. 15. Disengage the plunger rod from the cartridge unit holder while holding the needle down and away from the fingers or hands over a sharps unit (Figure 34-48).
This prevents the fingers from being in front of the needle.
FIGURE 34-48 After the injection is given, disengage the plunger from the cartridge unit.
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RATIONALE
PROCEDURAL STEPS 16. Unscrew the ribbed collar of the cartridge unit holder. 17. Allow the needle cartridge unit to drop into the sharps container (Figure 34-49).
This helps to prevent an accidental needlestick.
18. Cleanse the cartridge holder with an antiseptic cleanser and allow to dry.
This prevents crosscontamination from occurring to the next patient receiving medication from a prefilled cartridge.
FIGURE 34-49 Allow the cartridge to drop freely into the sharps container.
19. Cleanse the work area and remove gloves and wash your hands.
PROCEDURE 34-6 Administer an Intradermal Injection Objective: To administer an intradermal injection into a patient.
Equipment/Supplies: ❖ Appropriate sized needle and syringe unit with correct medication ❖ Antiseptic wipe ❖ Gauze 2x2 sponges PROCEDURAL STEPS
❖ Sharps container ❖ Disposable gloves ❖ Medication tray RATIONALE
1. Wash your hands.
This prevents the spread of infection and contamination during the procedure.
2. Assemble the equipment. Institute the Seven Rights of Drug Administration.
Instituting the seven rights helps to alleviate errors.
3. Identify the patient using two identifiers, identify yourself, and explain the procedure
Giving the medication to the wrong patient can cause serious problems for the patient.
4. Ask patient about drug allergies or latex allergies.
Giving the patient a drug or using products that the patient is allergic to can cause an anaphylactic reaction.
5. Select the proper injection site (anterior forearm or middle of back). 6. Cleanse the site with antiseptic and allow to air dry completely. (Cleanse in a circular motion working outward to an area of 2 to 3 inches.)
This prevents the possible contamination of the injection site and ensures the removal of microorganisms from the injection site area. Wet alcohol may cause the site to burn when you inject the medication.
A D M I N I S T R AT IO N OF PA R E N T E R A L M E D I C AT IO N S
PROCEDURAL STEPS
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RATIONALE
7. Prepare the equipment and apply gloves.
Wearing gloves prevents contamination of bloodborne pathogens during the procedure.
8. Remove the needle cap. Pull the cap straight off, never twist.
Twisting may loosen the needle attached to the syringe.
9. Stretch the skin taut at the site of administration.
This allows the needle to be inserted easier and keeps the tissue from moving during insertion.
10. Insert the needle at a 10° to 15° angle with the bevel upward just under the skin (Figure 34-50). 11. Inject the medication slowly and steadily. A wheal should form (Figure 34-51).
This allows the tissue to slowly displace and provides space for the fluid. If the needle is too deep, a wheal will not form and the injection will have to be repeated.
12. Remove the needle quickly at the same angle of insertion.
This prevents injury to the tissue.
13. Do not press on or massage the injection site. Do not apply a bandage to the site.
The medication will be dispersed into deeper tissue if pressure is applied to the area. A bandage will absorb the medication.
FIGURE 34-50 Insert the needle bevel up just below the surface of the skin.
FIGURE 34-51 A wheal will form if the procedure was performed correctly.
14. Properly engage the safety device on the needle and dispose of the needle–syringe unit in the sharps container.
Engaging the safety device will help to prevent an accidental needlestick.
15. Remove gloves and wash your hands.
This prevents contamination and the spread of infection.
16. Give proper patient education for caring for the site and inform the patient to wait 20 to 30 minutes.
The 20 to 30 minute wait is to observe the patient for anaphylaxis.
17. Perform post-injection observation and document the procedure in the patient’s chart and the appropriate logs.
Documentation illustrates that the procedure was performed.
DOCUMENTATION EXAMPLE:
05-22-XX 3:15 p.m.
Tubersol, 0.1 mL, ID , right lower forearm, per Dr. Jones. Manf – Kline Beecham, Lot number—K449, exp. date – 12/XX. Pt. tolerated well, instructions given to return to clinic 48–72 hours for PPD reading. – complications during post-injection observation. Sherri Jones, CMA (AAMA)
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PROCEDURE 34-7 Administer a Subcutaneous Injection Objective: To administer an injection through the subcutaneous tissue.
Equipment/Supplies: ❖ Appropriate sized needle and syringe unit with correct medication ❖ Antiseptic wipe ❖ Gauze 2x2 sponges PROCEDURAL STEPS
❖ ❖ ❖ ❖
Sharps container Disposable gloves Medication tray Adhesive bandage RATIONALE
1. Wash your hands.
This prevents the spread of infection and contamination during the procedure.
2. Assemble the equipment. Institute the Seven Rights of Drug Administration.
Instituting the seven rights will help prevent errors from occurring.
3. Identify the patient using two identifiers, identify yourself, and explain the procedure.
Giving the medication to the wrong patient can cause serious problems for the patient.
4. Ask the patient about drug allergies, latex allergies, or adhesive allergies.
Giving the patient a drug or using products that the patient is allergic to can cause an anaphylactic reaction.
5. Select the proper injection site (fatty tissue of the arms, thighs, or stomach). 6. Cleanse the site with antiseptic and allow to air dry completely. (Cleanse in a circular motion working outward to an area of 2 to 3 inches.)
This prevents the possible contamination of the injection site and ensures the removal of microorganisms from the injection site area. Wet alcohol may cause the site to burn when you inject the medication.
7. Prepare the equipment and apply gloves.
This prevents contamination by bloodborne pathogens during the procedure.
8. Remove the needle cap. Pull the cap straight off, never twist.
Twisting may loosen the needle attached to the syringe.
9. Grasp or pinch the tissue lightly with one hand.
This helps to determine the subcutaneous layer of tissue and helps with the needle insertion.
10. Insert the needle at a 45° angle with the other hand, using a quick and smooth motion (Figure 34-52). 11. Stabilize the needle within the tissue.
Unnecessary movement of the syringe can cause tissue damage and pain to the patient.
FIGURE 34-52 The proper angle of insertion for a subcutaneous injection
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RATIONALE
12. Aspirate to ensure the needle is not in a blood vessel.
If the needle has inadvertently been inserted into a vessel, there will be a bloody return into the syringe. Do not inject, but remove the needle immediately. Depositing medication into a blood vessel could cause harm to the patient.
13. Inject the medication slowly and steadily.
Injecting the medication too quickly can cause discomfort to the patient and not allow the medication to be absorbed properly.
14. Remove the needle quickly at the same angle of insertion.
This helps to prevent trauma to the tissue.
15. Place a cotton ball or gauze sponge over the injection site and gently massage the area, if applicable.
This helps ease the discomfort caused from the injection and accelerates absorption of the medication (unless massaging is contraindicated).
16. Properly engage the needle’s safety device and dispose of the needle and syringe into the sharps container. Apply a bandage to the site to prevent the patient’s clothes from becoming contaminated with blood.
Engaging the safety device helps to reduce the possibility of a needlestick.
17. Remove gloves and wash your hands.
This prevents contamination and the spread of infection.
18. Give proper patient educational materials and waiting instructions. 19. Perform post-check of the patient and site 20 to 30 minutes following the procedure.
Allergic reactions usually occur within 20 to 30 minutes of the procedure.
20. Chart the procedure correctly on the progress note and appropriate logs.
Documentation illustrates that the procedure was performed.
DOCUMENTATION EXAMPLE:
05-22-XX 3:15 p.m.
Varivax #1, 0.5 mL, sub-q, right arm per Dr. Sullivan. Manf.–Kline Beecham, Lot number–K449, exp. date – 12/XX. Pt. tolerated well, instructions given to pt. for site care and VIS sheet provided—consent form signed and filed in chart.. Post injection follow-up, –complications. Sherri Jones, CMA (AAMA)
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PROCEDURE 34-8 Administer an Intramuscular Injection Objective: To administer an injection within the muscular tissue.
Equipment/Supplies: ❖ Appropriate sized needle and syringe unit with correct medication ❖ Antiseptic wipe ❖ Gauze 2x2 sponges PROCEDURAL STEPS
❖ ❖ ❖ ❖
Medication tray Sharps container Disposable gloves Adhesive bandage RATIONALE
1. Wash your hands.
This prevents the spread of infection and contamination during the procedure.
2. Assemble the equipment. Institute the Seven Rights of Drug Administration.
Instituting the seven rights will help prevent errors from occurring.
3. Identify the patient using two identifiers, identify yourself, and explain the procedure.
This prevents the wrong patient from receiving the medication.
4. Ask the patient about drug allergies, latex allergies, or adhesive allergies.
Giving the patient a drug or using products that the patient is allergic to can cause an anaphylactic reaction.
5. Locate the proper injection site (deltoid, dorsogluteal, ventrogluteal, or vastus lateralis).
The right site must be selected in order for the drug to be absorbed properly.
6. Cleanse the site with antiseptic and allow to air dry completely. (Cleanse in a circular motion working outward to an area of 2 to 3 inches.)
This prevents the possible contamination of the injection site and ensures the removal of microorganisms from the injection site area. Wet alcohol may cause the site to burn when you inject the medication.
7. Prepare the equipment and apply gloves.
This prevents contamination by bloodborne pathogens during the procedure.
8. Remove the needle cap. Pull the cap straight off, never twist.
Twisting may loosen the needle attached to the syringe.
9. Stretch the tissue to hold the skin taut with your nondominant hand. 10. Using your dominant hand, insert the needle at a 90° angle using a quick and smooth motion (Figure 34-53).
This helps with the needle insertion.
11. Stabilize the needle within the tissue.
Unnecessary movement of the hand holding the syringe can cause tissue damage and pain to the patient.
12. Aspirate to ensure the needle is not in a blood vessel. If blood enters the syringe, do not inject, but remove the needle immediately. If there is no bloody return into the needle, proceed with the injection process.
Depositing the medication into the bloodstream could cause great harm to the patient.
FIGURE 34-53 The proper angle of insertion for an intramuscular injection
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13. Inject the medication slowly and steadily.
Injecting the medication too quickly can cause discomfort to the patient and not allow the medication to be absorbed appropriately.
14. Remove the needle quickly at the same angle of insertion.
This helps to prevent trauma to the tissue.
15. Place a cotton ball or gauze sponge over the injection site and gently massage the area, if applicable.
Massaging the area helps to disburse the medication, unless contraindicated.
16. Engage the safety device on the needle, and dispose of the needle–syringe unit in the sharps container.
This protects you from an accidental needlestick from a contaminated needle.
17. Place an adhesive bandage over the site and remove gloves and wash your hands.
This prevents contamination and the spread of infection.
18. Give related patient educational materials and proper waiting instructions. 19. Perform post-check of the patient and site 20 to 30 minutes following the procedure.
Allergic reactions usually occur within 20 to 30 minutes of the procedure.
20. Chart the procedure correctly on the progress note and appropriate logs.
Documentation illustrates that the procedure was performed.
DOCUMENTATION EXAMPLE:
05-22-XX 3:15 p.m.
Hepivax 0.5 mL, IM, R. Deltoid per Dr. Jones. Manf. – Kline Beecham, Lot number–K449, exp. date – 12/XX. Pt. tolerated well, instructions given to pt. for site care and VIS sheet provided and consent form signed and filed. No problems during post check. Sherri Jones, CMA (AAMA)
PROCEDURE 34-9 Administer a Z-Track Medication Objective: To administer an injection by the Z-track method
Equipment/Supplies: ❖ Appropriate sized needle and syringe unit with correct medication ❖ Antiseptic wipe ❖ Gauze 2x2 sponges
❖ ❖ ❖ ❖
PROCEDURAL STEPS
RATIONALE
1. Wash your hands.
Medication tray Sharps container Disposable gloves Adhesive bandage
This prevents the spread of infection and contamination during the procedure
2. Assemble the equipment. Perform the Seven Rights of Drug Administration. 3. Identify the patient using two identifiers, identify yourself, and explain the procedure.
This ensures that you do not give the wrong patient the medication. continues
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PROCEDURAL STEPS 4. Ask the patient about drug allergies, latex allergies, or adhesive allergies.
RATIONALE Giving the patient a drug or using products that the patient is allergic to can cause an anaphylactic reaction.
5. Locate the proper injection site (usually the dorsogluteal site). 6. Cleanse the site with antiseptic and allow to air dry completely. (Cleanse in a circular motion working outward to an area of 2 to 3 inches.)
Cleansing the site reduces microorganisms on the skin. Allowing the site to air dry helps to take away the sting when inserting the needle.
7. Prepare the equipment and apply gloves.
Gloves help to prevent contamination by bloodborne pathogens during the procedure in the event the site bleeds.
8. Remove the needle cap. Pull the cap straight off, never twist.
Twisting may loosen the needle attached to the syringe.
9. Using your nondominant hand, pull the tissue to be injected laterally 1 to 2 inches away from the injection site.
This displaces the tissue so when the tissue is released, the tissue will return to a normal position to prevent the medication from leaking out of the site and into surrounding tissue.
10. Using your dominant hand, insert the needle at a 90° angle with a quick and smooth motion. 11. Stabilize the needle within the tissue.
Unnecessary movement of the hand holding the syringe can cause tissue damage and pain.
12. Aspirate using the one-hand technique to ensure the needle is not in a blood vessel. If medication is in a blood vessel, remove the needle and prepare a new setup.
Using the one-hand technique when aspirating frees the other hand to keep the tissue retracted.
13. Inject the medication slowly and steadily.
Injecting the medication too quickly can cause discomfort to the patient and not allow the medication to be absorbed properly.
14. Wait 10 seconds before removing the needle.
This allows the medication to settle in the tissue.
15. Remove the needle quickly at the same angle of insertion. 16. Release the tissue after removing the needle from the site.
This allows the displaced tissue to return to a normal position and blocks the insertion path of the needle, preventing the medication from leaking into the surrounding tissues.
17. Place a cotton ball or gauze sponge over the injection site. Do not massage the site for a Z-track injection.
Massaging could possibly cause malabsorption of the medication, discoloration to the tissue surrounding the site, or even leakage of the medication from the injection site.
18. Properly engage the safety device and dispose of the needle–syringe unit into the sharps container. Apply a bandage to the site to prevent the patient’s clothes from becoming contaminated with blood.
Engaging the safety device keeps you from accidentally getting stuck with a contaminated needle.
19. Remove gloves and wash your hands.
This prevents contamination and the spread of infection.
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RATIONALE
20. Give related patient educational materials and waiting instructions. 21. Perform post-check of the patient and site 20 to 30 minutes following the procedure.
Allergic reactions usually occur within 20 to 30 minutes of the procedure.
22. Chart the procedure correctly in the progress note and appropriate logs.
Documentation proves that you performed the procedure.
DOCUMENTATION EXAMPLE:
05-22-XX 3:15 p.m.
Methylcobalamin, 1.0 mL, Deep IM (Z-Track), L. Dorsogluteal per Dr. Raymond. Manf. – Kline Beecham, Lot number–K449, exp. date – 12/XX. Pt. tolerated well, –complications during post injection check. Sherri Jones, CMA (AAMA)
Chapter Summary By learning the information provided in this chapter and performing the competencies, medical assistants will come to realize the importance of performing safe and competent invasive procedures for their patients’ health care needs. The practice of performing invasive procedures must be methodical, focused, and performed with the utmost care, not given light thought or compromising the quality of services provided. The standard of care demands a high level of achievement and understanding, for the protection of the patient and the provider’s practice.
FIELD APPLICATION CHALLENGE The physician asks you to administer a hormone shot that is very viscid and oily. As you go to withdraw the medication, you notice that you are having a great deal of trouble pulling back on the plunger. After preparing the medication, you go back to the patient’s room with the medication tray. You ask the patient where he wants to have the medication administered. The patient replies his arm and rolls up his sleeve. You start to administer the injection. You notice that it is very difficult to push forward on the plunger as you inject the medication into the patient’s deltoid. The patient appears to be experiencing a great deal of pain. Following the injection, the skin over the site is very reddened and a hard knot now appears at the injection site.
1. What are some possible causes for the difficulty in pulling back the plunger? 2. What should you have done when the patient asked for the injection in the arm? What would have been a better location? 3. What would have been an appropriate sized needle to use for this injection based on the new location of the injection and the viscosity of the medication? 4. Why do you suppose that the patient’s arm reddened and a knot appeared in the area where the injection was given?
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Chapter Assessment
Web Activity
1. What is the most important aspect of administration of medication to a patient? a. Documentation of the procedure b. Documentation of the medication administered to the patient c. Proper identification of the patient d. Proper technique in administering the medication
1. The Centers for Disease Control and Prevention National Immunization Program provides information on the importance of vaccinations. Go to http://www.cdc.gov and look up this important information. Prepare a one-page summary that depicts why the benefits of immunizing far outweighs the risks of immunizing.
2. Tuberculin syringes come in what syringe size? a. 1 mL syringes b. 3 mL syringes c. 5 mL syringes d. 10 mL syringes 3. The gauge of the needle indicates: a. the size of the lumen. b. the length of the needle. c. the length of the hub. d. the size of the syringe. 4. A subcutaneous injection is usually given at what degree for angle of insertion? a. 10° b. 15° c. 45° d. 90° 5. The two vaccines that are contraindicated for pregnant women are: a. hepatitis B and tetanus. b. Varicella and MMR. c. PPD and hepatitis B. d. small pox and hepatitis A. 6. The gauge used for an injection is determined by: a. the viscosity of the medication. b. the site of the injection. c. the amount of fat the patient has. d. all of the above. 7. Parenteral routes include all but which of the following? a. Intramuscular b. Intravenous c. Oral d. Intra-articular
CONNECTION Using your StudyWARE CD-ROM: ❖ Complete the Concentration activity for this chapter. ❖ Complete the Quiz for this chapter in Test Mode.
THE DVD LINK On your StudyWARE CD-ROM, go to the DVD Challenge for this chapter. View the DVD clip and respond to the following questions: 1. Once you load the cartridge into the injector device and lock it into place, what should you do with the medicine in the syringe to finalize the preparation of the syringe needle unit? 2. After administering the injection, what steps should you take to dispose of the cartridge unit?
C H A P T E R
Urgent Care and Emergency Procedures Chapter Outline On the Scene Emergency Procedures Responsibilities of a First Responder The Urgent Care Industry Departments within an Urgent Care Center
Preparing Personnel for Emergencies Triaging in Ambulatory Care Life-Threatening Conditions Anaphylaxis Bleeding Emergencies Non-Life-Threatening Emergencies
Developmental Objectives After completing this chapter, you should be able to: 1. Correctly spell and define the essential terms. 2. Discuss the role of the first responder both at the scene of an emergency and in the office. 3. List the meaning of each letter in the mnemonic ABCDDR and explain the procedure for each one. 4. Explain the purpose of the AVPU scale and what each letter represents.
35 Essential Terms abrasion acute abdomen anaphylaxis asthma automated external defibrillator AVPU scale cardiopulmonary resuscitation cerebrovascular accident (CVA) chest compression concussion crash cart defibrillation diabetic coma diaphoresis DOTS embolus first responder frostbite heat cramp heat exhaustion heat stroke continues
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KEY COMPETENCIES
CAAHEP
ABHES
Applying First Responder Principles during an Emergency (Including Adult CPR)
VI.A.1.a.4.e VI.A.1.a.4.f
Controlling Bleeding
VI.A.1.a.4. e VI.A.1.a.4.f
Splinting an Arm
VI.A.1.a.4.e VI.A.1.a.4.f
Treating the Patient for Shock
VI.A.1.a.4.e VI.A.1.a.4.f
5. Define cardiopulmonary resuscitation and explain its purpose. hemorrhaging hypothermia incision insulin shock ischemia laceration orthostatic hypotension paresthesia pulse oximeter puncture recovery position seizure shock syncope thrombus transischemic attack (TIA) traumatic brain injury triage ventilation ventricular fibrillation
6. Explain the function of urgent care centers and list the various departments found in an urgent care center. 7. List common medications and supplies found on a crash cart and explain each of their uses. 8. Define triage and discuss the role of the medical assistant in office triage. 9. List diseases and conditions that may be considered life threatening and describe the proper steps that are taken both in the office and at the scene for managing these conditions. 10. List patient conditions that are not considered life threatening and describe what factors should be considered in determining the order in which these patients are seen. 11. Discuss what signs the medical assistant should observe before and after splinting a patient’s limb.
Introduction Most people think of emergency medicine as something that only occurs at the scene of an accident or in a hospital trauma center; however, ambulatory health care centers also get their fair share of smaller-scale emergencies. This is especially true with the booming urgent care industry. Urgent care centers are popping up all over the country. Many of these centers are staffed with emergency medical technicians (EMTs), paramedics, nurses, and medical assistants. Medical assistants need to know not only how to respond at the scene of an emergency, but also how to properly assist patients upon their arrival at the office. The contents of this chapter will provide the medical assistant with the knowledge that is necessary to perform well both at the scene of an emergency and in urgent care situations.
ON THE SCENE EMERGENCY PROCEDURES The first part of this chapter will reinforce some of the basic principles taught during professional CPR and first aid training and will focus on being a first responder at the scene of an emergency. The information in this chapter is by no means a
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substitute for professional first aid and CPR training. All medical assisting students should have formal first aid and CPR training prior to going into their externship program.
gas fumes or chemicals that would indicate a chemical spill or gas leak and should never enter a crime scene until it has been properly secured.
Responsibilities of a First Responder
Another component of scene safety is the possibility of disease transmission through contact with body fluids containing pathogens for diseases such as hepatitis B or HIV. Rescuers should apply PPE including gloves, gown, mask, and goggles (Figure 35-1) when exposure to these fluids is likely.
A first responder is the first person to arrive at the scene of an emergency trained to respond to the needs of the victim. Most businesses, including physicians’ offices, have first responder teams that have been specially trained to perform first responder duties. Whether in the office or at the scene of an emergency, there are certain steps that first responders should perform: 1. Determine scene safety. This is most important when the emergency takes place somewhere other than the office, such as the scene of a car accident or a house fire. Responders should ask the question, “Is my life going to be in danger as a result of assisting the victim?” 2. Whenever possible, apply personal protective equipment (PPE). 3. Establish unresponsiveness and check to see if the victim has a MedicAlert bracelet or product on that may signal what is going on with the victim. If the victim is unconscious, do the following: Urgent Care Tips: ↓ Alert co-workers and physician (have someone call 911)
At the Scene Tips: ↓ Establish the EMS (call 911)
4. Perform the following mnemonic: ABCDDR ❖ A = Airway: Open the airway. ❖ B = Breathing: Check breathing and administer ventilations, if necessary. ❖ C = Circulation: Check for circulation and administer compressions, if necessary. ❖ D = Defibrillation: Obtain an AED and administer shocks, if necessary. ❖ D = Disabilities: Check for other disabilities. ❖ R = Respond: Respond to the victim’s condition or injury.
Determining Scene Safety Scene safety must always be considered when providing emergency care. When at the scene of an emergency, the rescuer should check to make certain that there are no obstacles that may cause the scene to be unsafe, such as live wires dangling over the work area or a risk of being hit by oncoming traffic. Rescuers should pay close attention to odors in the area such as
Applying PPE
Establishing Unresponsiveness In order to determine the patient’s level of consciousness, a response assessment should be performed. A scale that is commonly used by medics (but may be used by other health care professionals) to determine responsiveness is referred to as the AVPU scale. Refer to Table 35-1 for information about this scale. The category that best describes the victim’s state of consciousness is the one that the rescuer will share with EMS personnel upon arrival. A good time to check to see if a victim has a MedicAlert product on is during this part of the assessment. MedicAlert products, such as necklaces, bracelets, sports bands, and stretch bands (Figure 35-2), can provide clues to determine the victim’s condition that can save precious time. Even though these products are designed especially for medics, any first responder can benefit from information listed on these products. MedicAlert products are engraved with the name of the victim’s medical condition(s), ID number, and the 24-hour emergency response center number that can be called to gather additional information. FIGURE 35-1 Examples of PPE items that should be applied to institute infection control measures during emergencies
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TABLE 35-1 Responsiveness Table LETTER
STANDS FOR
MEANING
A
Alert
The victim is awake and alert and able give a name, the date, the location, what happened, etc.
V
Responds to verbal stimuli
The victim responds to a voice (though the eyes may not be open) and is able to appropriately answer questions when spoken to.
P
Responds to painful stimuli
The victim only responds when in pain, such as when an area that has been injured is touched or the ear is gently pinched.
U
Unresponsive
The patient is not awake and does not respond to any type of stimuli.
Airway, Breathing, and Circulation (ABC) After checking for unresponsiveness, the rescuer should begin the ABCs of CPR. CPR stands for cardiopulmonary resuscitation and means to restore heart and lung function. The “A” in ABC stands for airway. The rescuer should position the head to make certain that the airway is open. If neck injuries are not likely, the rescuer may use the head tilt/chin lift maneuver (Figure 35-3a) for opening the airway. If cervical spine injuries are likely, the rescuer should use the jaw thrust maneuver to open the airway (Figure 35-3b). This technique allows the rescuer to open the airway without causing further damage to the victim’s head or neck. The “B” in ABC stands for breathing. The rescuer should check for breathing by looking for the rise and fall of the chest and listening and feeling for air escaping from the victim’s mouth (this step should take approximately five seconds). If no breathing is present, the rescuer should place a transparent mask with a one-way valve (Figure 35-4) over the victim’s mouth
and nose. This will help protect the rescuer from being exposed to secretions in the victim’s mouth. The rescuer should then deliver two effective breaths (breaths that cause the victim’s chest to just slightly rise and fall) by blowing through the mouthpiece on the mask. The “C” in ABC stands for circulation. The rescuer should check for signs of circulation by looking for any signs of movement or coughing (this step should take no longer than 10 seconds). Professional rescuers (such as the medical assistant) will also perform a pulse check to determine if the victim’s heart is beating by placing two fingers over the carotid artery in adults and children, and over the brachial artery in infants. If a pulse is present but there is still no breathing, the rescuer will provide rescue breaths consisting of one breath every five to six seconds in victims above the age the age of puberty, and one breath every three to five seconds for victims below the age of puberty, while continuing to look for signs of movement. If no pulse is present, the rescuer should start performing chest compressions (Figure 35-5), a maneuver in which
FIGURE 35-2 Examples of MedicAlert Products (Courtesy of the MedicAlert Foundation, Turlock, CA.)
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FIGURE 35-5 The proper hand positioning for CPR on an adult victim.
the rescuer pushes up and down on the lower half of the sternum several times to compress the heart. Chest compressions assist in delivering the oxygen that was ventilated into the patient’s lungs during the breathing phase throughout the body.
(b)
FIGURE 35-3 (a) When there is no sign of head or neck injuries, the rescuer may use the head tilt/chin lift procedure to open the airway. (b) When head or neck trauma is suspected, the rescuer should use the jaw thrust maneuver to open the airway.
FIGURE 35-4 Using a mask with a one-way valve will keep vomitus and other oral secretions coming from the victim’s mouth from getting into the rescuer’s mouth.
Performing Chest Compressions on an Adult Rescuers should position themselves directly across from the victim’s chest and place the heel of one hand on the lower half of the sternum, between the nipples. Next, the rescuer will place the opposite hand over the first hand and interlock or straighten the hands so that only the heel of one hand is actually on the sternum. Locking the arms in place, the rescuer will compress the sternum 11⁄2 to 2 inches using the strength from the body, not the arms. The rate of compressions should be somewhere around 100 compressions/minute. (Compression rate refers to the speed of the compressions, not the actual number of compressions given in a oneminute time span.) After performing 30 compressions, the rescuer should give two more breaths and repeat four more sets of 30 compressions to two ventilations. The rescuer will check for breathing and signs of circulation after five complete cycles of 30 compressions to two ventilations, or about two minutes of CPR. If there is still no pulse or respiration, the rescuer will repeat several more cycles of compressions and ventilations and check for circulation every two minutes thereafter. If the victim has a pulse but no breathing, the rescuer will perform mouth-to-mask breathing, giving one breath every five to six seconds (in the adult) while continuing to monitor the pulse.
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The rate and depth of compressions will vary with different age groups. Medical assistants will learn all of the unique differences during a formal CPR training program. In offices that have access to an AED, one worker should start CPR, while the other worker retrieves the AED. Defibrillation shocks should be delivered as soon as the unit becomes available.
Providing Defibrillation (D) Ventricular fibrillation is a condition in which the heart twitches or flutters with no organized movement. This is one of the most common rhythms that occurs in adult victims of sudden cardiac arrest. Defibrillation is a procedure in which drugs or electrical shocks are used to restore normal contractions. Early defibrillation is necessary to keep the heart from stopping altogether. An automated external defibrillator (AED) (shown in Figure 35-6) is a type of defibrillator that allows persons with very little training the ability to provide shocks to a victim who is in VF. These units can be found in factories, airports, bus stations, and shopping malls. AEDs are also found in many urgent care centers and physicians’ offices. Some tips for using an AED include the following: ❖ Do not use defibrillators on infants. ❖ Defibrillators should be used as soon as possible on adult victims of cardiac arrest. ❖ Defibrillators should only be used on children when someone witnessed the arrest and feels certain that it is not related to respiratory arrest, or after providing two minutes of CPR during an arrest in which there were no witnesses.
FIGURE 35-6 The Philips HeartStart FR2+ ECG/EKG (Courtesy Philips Healthcare, www.medical.philips.com/goto/HeartStart.)
❖ The rescuer should make certain that the skin is clean and dry before placing the pads on the chest. ❖ The rescuer should remove any transdermal patches on the victim’s chest. These patches may prevent the flow of electricity or cause the patient to obtain a burn. Rescuers should wear gloves when removing transdermal patches to prevent the medication on the patch from being absorbed into the rescuer’s skin. ❖ The rescuer should never give shocks when the victim is in water or on metal surfaces. This may cause both the rescuer and the victim to receive burns. ❖ If the victim has a pacemaker, the rescuer should place electrode pads about 1 inch from the pacemaker. The AED will usually have a list of instructions secured to the unit; however, the major steps are the same from unit to unit and include the following: 1. Turn the power on. 2. Attach the electrode pads (each unit usually illustrates where to place the pads). Figure 35-7 shows the proper placement of the pads. 3. Clear the victim and press “Analyze” (the unit will be able to determine if a shock is necessary during the analyzing cycle). If a shock is necessary, the rescuer will be instructed to stand clear of the victim and press “Shock.” Once the shock has been delivered, the rescuer will give two more minutes of CPR before reanalyzing to determine if the victim needs another shock.
FIGURE 35-7 The proper electrode placement for the AED pads: One of the pads should be placed under the clavicle on the right side of the sternum and the other pad should be placed at the apex of the heart along the lower left rib cage.
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When working in the field, the AED should be used as soon as it is available, usually after the first pulse check. Important note: In order to become certified or registered, medical assistants are now required to take an official CPR class through a nationally recognized organization such as the American Red Cross. Therefore, this text will not provide performance checklists for specific CPR procedures.
Checking for Disabilities (D) Once the victim has been cleared through the ABCD portion of the assessment, the rescuer should check for other disabilities. A mnemonic that is commonly used during this part of the assessment is referred to as DOTS (deformities, open injuries, tenderness, or swelling). The rescuer should perform a head-to-toe assessment of the victim to establish if there are any disabilities and should not lift or move the head if head or neck trauma is suspected. Rescuers should make a note of any disabilities and share the information with the medics upon arrival or with the physician during office emergencies. The first responder should learn how to control bleeding and how to splint limb injuries (this information can be found later in the chapter). If there are any open injuries (injuries that break the skin), the rescuer should cover the site with a sterile/clean bandage so that the victim does not become alarmed.
Responding to the Victim’s Condition or Injury (R) Once the rescuer has performed the ABCDD portion of the assessment, the rescuer will perform the “R” portion of the assessment, which is responding to the remainder of injuries sustained by the victim. This may include controlling bleeding, splinting a limb, or treating the victim for shock. A position that is commonly used to manage victims until the EMS arrives is referred to as the recovery position (Figure 35-8). To place the victim in this position, the victim is carefully rolled over onto the side (as long as there are no neck injuries). This position will keep the patient from choking in case of vomiting and assists in keeping the airway open. Procedure 35-1 provides steps for acting as a first responder.
Good Samaritan Laws The purpose of Good Samaritan laws is to protect bystanders from being held liable for civil damages from unintentional injuries or death that may occur while assisting victims during an emergency health crisis. In order for the law to apply, the services have to
FIGURE 35-8 Whenever possible, patients should be placed in the recovery position to maintain the airway until the EMS arrives.
be rendered outside of a hospital or medical office setting and must be administered without the expectation of compensation. The laws are designed to encourage persons with professional training to assist victims during emergencies without the fear of legal consequences in the event that complications arise.
THE URGENT CARE INDUSTRY Urgent care is one of the fastest growing professions in the United States. More urgent care centers are now opening than managed care centers according to the National Association for Ambulatory Care. The types of conditions seen in urgent care range from very minor symptoms such as a sore throat to life-threatening emergencies, such as cardiac arrest. Urgent care centers are usually not equipped to handle traumatic emergencies; therefore, emergency services do not transport patients to urgent care cen-
TOOL BOX
C R I T I C A L T H I N K I NG CHALLENGE The receptionist calls you to tell you that a patient has just collapsed in the reception area. The physician just ran downstairs to consult with a specialist and there are no other clinical team members available. When you get to the reception area, several other patients are surrounding the victim. 1. What should you do first?
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ters. Patients that do enter the urgent care center with life-threatening symptoms are usually stabilized and transported to nearby hospitals. Although urgent care centers routinely see patients with acute conditions and smaller-scale emergencies, they also provide a variety of other services including: ❖ Preemployment physicals ❖ Immigration examinations ❖ Worker’s compensation services
Departments within an Urgent Care Center Urgent care centers typically have several departments, including the acute care area, a laboratory, an x-ray facility, and a pharmacy. These urgent care centers may be thought of as mini health care malls. They are designed to provide several heath services within one location.
Acute Care Area Patients will usually enter the acute care area through the reception room. The patient will sign in and
explain the reason for the visit. Administrative staff members are usually trained to recognize patients with potentially life-threatening symptoms and will direct those patients back to the triage area for an immediate workup. The order in which patients are seen in an urgent care facility is first determined by the seriousness of each patient’s symptoms and then the order of each patient’s arrival. In the triage or screening area, the medical assistant will obtain the patient’s chief complaint and perform a set of vital signs. The patient is then escorted to the appropriate room. Rooms in the urgent care center are usually assigned special names such as the cardiac bay or trauma room, procedure room, or examination room. The names of the rooms may vary a bit from facility to facility. The medical assistant should try to match the patient’s complaint with the appropriate room whenever possible. Table 35-2 provides a sampling of what some urgent care centers follow in regards to room assignments. The Cardiac Bay Area/Trauma Room The cardiac bay (Figure 35-9) or equivalent is a room that is nor-
TABLE 35-2 Urgent Care Room Assignments CARDIAC BAY/TRAUMA ROOM
PROCEDURE ROOM
BASIC EXAMINATION ROOM
Abdominal pain (acute and severe cases)
Anxiety symptoms (severe, as in a panic attack)
Abdominal/stomach pain (mild cases)
Anaphylactic reactions
Bleeding emergencies
Anxiety symptoms (mild)
Asthma attacks/breathing emergencies
Soft tissue injuries
Burns (mild)
Cardiac emergencies
Burns (moderate to severe)
Cold/allergy/sinus symptoms (earache, sore throat, sinus pain and pressure)
Head and neck injuries (severe)
Dehydration symptoms
Psychiatric emergencies
Heat stroke and hypothermia symptoms
Eye injuries
Fever
Poisonings and drug-related emergencies
Head or neck injuries (minor)
Headache
Shock symptoms
Musculoskeletal injuries or symptoms (strains, sprains, and fractures)
Insect stings or bites (local reactions)
Stroke symptoms
Wounds (abrasions, lacerations, and punctures)
Rashes and skin disorders
Unconsciousness
Urinary tract disorders
Seizures
Vaginal and penile symptoms
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FIGURE 35-9 A trauma room or cardiac bay area in an urgent care center
mally stocked with equipment and supplies that are used during a life-threatening emergency. Types of emergency equipment and supplies found in this area include: 1. Oxygen and tubing 2. Pulse oximeter: A device used to measure the oxygen saturation level of the blood. A procedure for performing pulse oximetry can be found in Chapter 16. 3. IV pole and IV medications 4. Crash cart: A cart that stocks all of the medications and supplies used in an emergency 5. Cardiac monitor Tables 35-3 and 35-4 list common items that are stocked on a crash cart. Figure 35-10 shows a crash cart and some of the items that are normally stocked within it. The cardiac bay or trauma room should be reserved for life-threatening emergencies and should not be used for routine illnesses or injuries unless the physi-
FIGURE 35-10 A crash cart and common supplies found on a crash cart
cian specifies it to be used as an overflow room when the urgent care center is extremely busy. The Procedure Room The procedure room is usually a room a little larger than the cardiac bay that stocks suture materials, casting equipment, splints, bandage materials, and other supplies (Figure 35-11). The types of patients that are usually placed in this room are patients needing special procedures performed, including patients with limb injuries, lacerations, cysts, and severe burns. On occasion, this room may be used as an overflow room when all other examination rooms are full (check institutional policies).
TABLE 35-3 Common Items Stocked on a Crash Cart EQUIPMENT AND SUPPLIES
RESPIRATION DEVICES
Adhesive tape, alcohol wipes, bandage supplies, scissors, iodine swabs, alcohol wipes, tongue blades, tourniquets, blood pressure equipment, gloves (both sterile and nonsterile), glucose supplements, hot and cold packs, IV tubing, penlight, PPE, syringes, needles, AED
Airways (both nasal and oral in all sizes), bag-mask equipment, laryngoscope, oxygen mask/tubing and equipment, suctioning equipment
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TABLE 35-4 Crash Cart Medications and Their Common Uses NAME
USED FOR
Activated charcoal
Ingestion of poisons
Aminophylline
Acute asthma attacks or bronchial spasms
Atropine
Asystole and bradycardia
Albuterol (Proventil)
Acute asthma attacks or bronchial spasms
Diazepam (Valium)
Anxiety and seizure disorders
Digoxin (Lanxoin)
Heart failure and atrial fibrillation
Diphenhydramine (Benadryl)
Allergic or hypersensitivity reactions
Dopamine (Intropin)
Hypotension (shock)
Epinephrine (Adrenaline)
Acute allergy reactions Cardiac rhythm restoration during cardiac arrest
Furosemide (Lasix)
Congestive heart failure Pulmonary edema
Glucagon or glucose
Hypoglycemia or insulin shock
Intravenous solutions (Dextrose (5%), normal saline, and Ringer’s Lactate solution)
Rehydration Vehicle to deliver intravenous medications
Isoproterenol (Isuprel)
Acute conditions of bradycardia
Lidocaine (Xylocaine)
Ventricular arrhythmias
Naloxone (Narcan)
Drug overdoses, shock, alcoholic coma, schizophrenia, Alzheimer’s disease
Nitroglycerine (Nitrostat)
Angina and MI
Norepinephrine (Levophed)
Acute hypotension
Phenobarbital (Bellatal; Solfoton)
Seizures
Phenytoin (Dilantin)
Seizures
Sodium bicarbonate
Cardiac arrest
Verapamil (Calan)
Ventricular tachycardia
FIGURE 35-11 The procedure room has many of the supplies necessary to perform procedures such as casting, splinting, and suturing.
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Regular Examination Rooms Regular examination rooms are used for all patients that do not fit into the life-threatening and special procedures categories. Patients with sore throats, urinary symptoms, and gastrointestinal symptoms are examples of patients placed in these types of rooms.
PREPARING PERSONNEL FOR EMERGENCIES All medical facilities, especially urgent care centers, should provide employees with emergency and disaster training. Employees should learn their responsibilities during life-threatening emergencies and in other disasters, such as a fire or tornado. This chapter will focus on how to respond during life-threatening emergencies. Table 35-5 lists typical duties of various staff members during life-threatening emergencies.
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those delivering emergency care on the battlefield and refers to a process in which things are ranked in terms of importance or priority. Hospital ER departments have triage stations where specially trained nurses and medics take the patient’s complaint and vital signs and determine the severity of the patient’s symptoms. Once the patient has been assessed, the patient is either immediately placed in a room or sent back to the waiting area. Routine medical offices rarely see patients with life-threatening disorders, so the triaging or screening process is not nearly as intense as while working in a hospital ER. However, there may still be times when prioritizing is necessary. Because urgent care offices see many smaller-scale emergencies, prioritization of symptoms is a must. Patient order is determined by the seriousness of the patient’s symptoms. Thus, patients with potentially life-threatening conditions should be examined prior to patients with non-life-threatening emergencies.
Life-Threatening Conditions
The term triage is a French term that originated in 1794 from a French military surgeon by the name of Baron Dominique Jean Larrey. It was designed to assist
Life-threatening conditions should take precedence over all other emergencies. The following conditions should be treated as life-threatening conditions.
TABLE 35-5 Staff Responsibilities during an Emergency ADMINISTRATIVE STAFF
CLINICAL STAFF
PHYSICIAN
Dispatch the EMS, poison control center, hospital, etc. (emergency phone numbers should be posted beside each telephone).
Recognize and respond to the emergency.
Assess the patient immediately and determine the need for EMS support.
Provide liaison services between the clinical staff and waiting family members.
Alert other team members of the emergency.
Give clinical staff appropriate instructions.
Obtain billing information from family members during the emergency or from the patient following the emergency.
Clinical responsibilities may include any of the following: • Vital sign measurement • Dressing application/assisting with casting • Pulse oximetry • Providing CPR • Gathering supplies from the crash cart • Oxygen administration • Assisting with IV therapy
• Administer appropriate medications. • Use the defibrillator, if necessary. • Monitor the patient continuously throughout the emergency. • Provide physical and emotional support.
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Acute Abdominal Emergencies Acute abdomen is a term that refers to the sudden or abrupt onset of intense abdominal pain and related symptoms, which may include fever, vomiting, diarrhea, dyspnea (difficult breathing), and shock. Sudden abdominal pain should be treated as a life-threatening emergency until a diagnosis can be made. Chronic abdominal pain is usually not classified as a lifethreatening emergency. Organs that may be involved in acute abdomen emergencies include the appendix, gall bladder, intestines, and spleen. Related conditions include appendicitis, the rupture of any of the above organs, and hemorrhage. Urgent Care Tips: The patient should be treated as an emergency and placed in the room where life-support equipment and supplies are available. Patients complaining of abdominal pain should not be allowed to eat or drink anything in the event that surgical inter-
vention becomes necessary. The medical assistant should alert the physician as soon as possible of the patient’s symptoms and prepare for the patient to have emergency lab work and x-rays conducted.
Anaphylaxis Anaphylaxis is a severe allergic reaction to an allergen usually in the form of a food, medication, chemical, or insect sting or bite. It is a systemic reaction (meaning that it affects the entire body) and typically occurs within minutes to two hours following contact with the allergen, but may be delayed as much as four hours. Refer to Table 35-6 for a more detailed listing of the timeline for the onset of symptoms related to the source of the allergen. After an initial exposure to the allergen, the person’s immune system may become sensitized to the offending agent. During subsequent exposures, a severe allergic
TABLE 35-6 Timelines for Symptoms Based on the Source
SOURCE
TIMELINE FOR ANAPHYLAXIS TO KICK IN
Food
Minutes to two hours
Peanuts, tree nuts (walnuts, cashews, etc.), shellfish, fish, milk, and eggs are examples of foods that are commonly seen as causes of anaphylactic reactions. It may only take a trace amount of the food product to stimulate a reaction. Individuals who are allergic to foods and have asthma are believed to be at a higher risk for developing an anaphylactic reaction.
Medications
Typically occur within one hour, but may be several hours later in rare cases
According to literature from the American Academy of Allergy, Asthma and Immunology, “The chances of developing an allergic reaction may be increased if the drug is given frequently, in large doses, or by injection rather than by pill.” Examples of drugs that may be more likely to provoke a reaction include antibiotics such as penicillin and tetracycline and certain pain relievers such as morphine and codeine. Patients receiving allergy injections are always in danger of anaphylaxis.
Insect stings or bites
Usually occurs within minutes, but may also be delayed
Honeybees, bumblebees, yellow jackets, hornets, wasps, fire ants, and harvester ants are the most common causes of insect stings in the United States.
Latex
Anaphylaxis may be immediate, but delayed sensitivity reaction may occur 12 to 36 hours later, usually in the form of redness and blistering.
Those who wear latex frequently have an increased risk of becoming sensitized to latex. Patients with spinal bifida and patients who have had multiple urinary surgeries seem to be at a higher risk than others of developing a latex allergy.
INTERESTING FACTS
Source: Food and Allergy Anaphylaxis Network at www.foodallergy.org/allergens/index.html.
URGENT CARE AND EMERGENCY PROCEDURES
reaction may occur, promoting the release of histamine throughout the body’s tissues. Histamine affects various systems of the body in different ways. The following is a list of the effects of histamine on different body systems during an anaphylactic crisis: ❖ Respiratory system: Histamine causes the bronchial tubes to constrict, resulting in bronchospasms. ❖ GI tract: Histamine can cause cramping, vomiting, and diarrhea. ❖ Circulatory system: Histamine causes vasodilation, which in turn promotes hypotension, or a dip in blood pressure, and a leaking of fluid from the blood vessels into the body’s tissues. The leaking of the blood vessels causes blood volume to diminish, resulting in shock. ❖ Integumentary system: Histamine can cause hives to occur throughout the body but may be more prevalent on the lips, tongue, and throat, blocking critical air passages. Eventually, if left untreated, the patient will go into cardiac arrest and die. Symptoms of anaphylaxis include a rapid or weak pulse, confusion, slurred speech, reddish skin, rash, or hives on the body with severe itching, swollen throat, hoarseness, swelling in other parts of the body, syncope, breathing problems, cyanosis, abdominal cramping, diarrhea, vomiting, heart palpitations, and chest tightness. Urgent Care Tips: If a patient develops anaphylaxis, the medical assistant should alert the physician right away and perform CPR, if necessary. Other staff members should be alerted and an emergency dose
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of epinephrine should be prepared. (The physician will usually order a 1:1000 solution of epinephrine, ranging anywhere from 0.2 to 0.5 mL, to be given IM. This will vary according to the patient’s age, size, and the magnitude of the emergency.) Some centers stock EpiPens. The medical assistant should never administer any medication without a direct order from the physician.
Bleeding Emergencies Hemorrhaging is a term that means uncontrollable bleeding. It is usually the result of a traumatic injury. Any time a patient severs a major blood vessel, it can lead to hemorrhage and shock. Most patients who are truly hemorrhaging will go directly to the ER; however, occasionally patients will show up at the urgent care with a bleeding crisis that should be managed in an ER. Refer to Table 35-7 for examples of blood vessels that may be involved during a bleeding emergency. Urgent Care Tips: 1. Apply direct pressure to the site with a stack of sterile gauze. 2. Elevate the affected area (Figure 35-12). 3. Apply pressure to the appropriate pressure points. Figure 35-13 illustrates the various arteries in the body that can be used to help stop or control bleeding. 4. Apply a pressure bandage if appropriate. 5. Tie a tourniquet just above the site of the injury labeled with the time that the tourniquet was applied. Tourniquets should only be applied by the provider when working in an office.
TABLE 35-7 Blood Vessels That May be Involved during a Bleeding Emergency POSSIBLE LOCATION
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SYMPTOMS
SEVERITY
Artery
Bright red blood that spurts from the open artery every time the heart beats
Very severe, hard to control, and could lead to death if it is a major artery
Vein
Dark red blood due to the lack of oxygen Does not usually spurt out, but will flow steadily out of the vein
May cause great blood loss, but is not as severe as an arterial injury because of the lower pressure in the vein
Capillary (located between veins and arteries)
Usually dark red blood that just gently oozes May be accompanied by clots
Not considered life threatening or severe Easy to control with direct pressure
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FIGURE 35-12 The medical assistant is applying direct pressure and elevating the patient’s arm to control the patient’s bleeding.
Refer to Procedure 35-2 for a complete procedure on controlling bleeding.
Internal Bleeding Internal bleeding is very difficult to recognize because it is not something that can be observed with the naked eye. It may be the result of a traumatic injury such as a fractured pelvis or gunshot or knife wound, or may occur following a surgical procedure. Symptoms include rapid and weak pulse, shallow breathing, hypotension, dizziness, cold and clammy skin, excessive thirst, and an overall feeling of anxiousness. There may also be skin discoloration, pain, and swelling at the site of the hemorrhage. Common sites for internal bleeding are the extremities, abdomen, and head. In the event that the physician suspects internal bleeding, the EMS should be alerted and the patient should be instructed to lie completely still. Monitoring of the patient’s breathing, circulation, and mental status should be performed while waiting for the EMS, and the patient should be treated for shock by elevating the patient’s feet and keeping the patient warm.
FIGURE 35-13 Common arteries that can be used to control bleeding
Breathing Emergencies Asthma is a chronic lung disease that causes the bronchial tubes to constrict and blocks the flow of air to and from the lungs. It quite often is the result of allergens, but may be exacerbated by physical activity and stress. Other conditions that may provoke breathing emergencies include foreign bodies in the respiratory tract, emphysema, Sudden Infant Death Syndrome (SIDS), and chronic obstructive pulmonary disease (COPD). Breathing emergencies will eventually lead to cardiac failure; therefore, prompt treatment is essential. Symptoms may include blueness of the lips and nail beds, a wheezing sound coming from the lungs, and an inability to breathe. Urgent Care Tips: Alert the physician as soon as possible. Place the patient in a semi-Fowler’s position and
URGENT CARE AND EMERGENCY PROCEDURES
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CR ITI C A L TH I N K I N G C H AL LEN G E
PATIENT TUTOR
You take a phone call from a patient that just had surgery. The patient just does not feel right and the patient’s heart is racing. 1. What other questions should you ask the patient to obtain a better grasp of the patient’s condition? 2. What piece of information did the patient provide that should send up an automatic red flag? 3. What could be wrong with the patient and what should be your next course of action?
attach a pulse oximeter to the patient’s index finger. Gather oxygen, IV, and respiratory medications along with the crash cart. Be prepared to perform rescue breathing and CPR, if necessary, and monitor vitals. If the patient has an obstructed airway, perform abdominal thrusts. Choking Emergencies Choking is a common cause of breathing emergencies, especially in children. Patients should be educated on how to prevent choking emergencies. The Patient Tutor tool box on this page lists choking prevention tips and should be given to patients that experience choking emergencies and all parents of young children. The universal distress signal for a choking victim is the placement of the victim’s hands around the throat. If an adult or child appears to be choking while in the office, the medical assistant should ask if the patient can speak (victims with a truly blocked airway will be unable to speak). Once the medical assistant has established that the patient is choking, the medical assistant should get positioned behind the patient, placing the dominant leg between the patient’s legs (this is to support the patient in the event that the patient collapses). Next, the medical assistant should wrap the arms around the patient’s waist and make a fist, placing it in between the patient’s naval and sternum (Figure 35-14). The medical assistant should then give the patient several upward abdominal thrusts until the object is dispelled or the patient becomes unconscious. Infants should receive a combination of back blows (Figure 35-15a) and chest thrusts (Figure 35-15b) to relieve airway obstructions.
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Provide patients with the following choking prevention tips: Adults: • Limit alcohol intake during meals, as this could affect the ability to properly chew and swallow food. • Avoid putting items in the mouth, such as hair pins and safety pins. • Take small bites of food and chew food completely. Children: • Do not allow children to play with anything smaller than the opening of the mouth. • Vacuum floors on a regular basis. • Keep all balloons, whether inflated or deflated, out of the reach of a child. • Check toys regularly to make certain there are no loose pieces, such as an eye or a nose that can become detached and picked up by the child. • Check bottle nipples and pacifiers often for any cracks or pinches. Discard any that appear not to be intact. • Cut solid food such as grapes and hotdogs into very small pieces. • Do not give hard foods such as candy, nuts, and seeds to children under the age of four. • Do not allow children to play with food in their mouths.
FIGURE 35-14 The proper placement of the rescuer’s hands when giving abdominal thrusts to relieve an obstructed airway
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FIGURE 35-15a When infants have an obstructed airway, the
FIGURE 35-15b The rescuer then gives the infant chest
rescuer starts by administering back blows to the infant.
compressions to assist in expelling the object from the infant’s airway.
Medical assistants should learn formal training techniques for managing blocked airways during CPR training.
type of diabetic emergency the victim is experiencing. Refer to the questions below:
Diabetic Emergencies Diabetic emergencies can be very serious and even life threatening. Medical assistants should become familiar with the signs of both diabetic coma and insulin shock. Diabetic coma is a life-threatening condition in which the patient’s blood sugar is dangerously high, causing the patient to go into a coma. Insulin shock is a life-threatening condition in which the patient’s blood sugar drops to a dangerously low level, causing the patient to go into shock. Medical assistants should know how to properly respond in the event of a diabetic crisis. When acting as a rescuer at the scene, check to see if victim is wearing a MedicAlert product. Many diabetics wear these products to help professional rescuers know about their condition in the event that a crisis occurs. Don’t rule out a diabetic crisis just because the victim is not wearing a MedicAlert product. Many diabetic patients do not wear these products because they don’t want the general public to know about their condition. If the victim is conscious, the rescuer should ask the victim a list of questions that will help determine the
1. Are you a diabetic? If yes, Type 1 or 2? 2. What type of medication do you take for your diabetes? 3. When was your last dose of medication, and how much did you take? 4. When did you eat last? (Especially important for patients with hypoglycemia.) 5. Have you recently exercised? (Exercise lowers blood sugar.) 6. Have you been sick to your stomach or throwing up? (Especially important for patients with hypoglycemia.) 7. Do you feel confused? (Often seen in hypoglycemia patients.) 8. Have you had a recent infection? (Could be related to hyperglycemia.) Table 35-8 depicts the differences between insulin shock and diabetic ketoacidosis, which can lead to diabetic coma. When on the scene, if unsure whether the victim is suffering from hyperglycemia or hypoglycemia, treat for hypoglycemia. Hypoglycemia is usually more serious than hyperglycemia, due to how quickly the patient deteriorates.
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TABLE 35-8 Differences between Insulin Shock and Diabetic Ketoacidosis INSULIN SHOCK
DIABETIC KETOACIDOSIS/COMA
Low blood sugar: Causes include an overdose of insulin or hypoglycemic medications, vomiting/ diarrhea, lack of food/dieting, or excessive exercising.
High blood sugar: Causes include excessive eating, not taking insulin or oral hypoglycemic, fever/ infections, and stress.
Immediate onset
Gradual onset
Pulse is full and pounding.
Pulse is weak and thready.
Respiration is normal to shallow.
Respiration is rapid and deep.
Skin is pale, cool, and clammy.
Skin is red, hot, and dry.
Lightheadedness or shaky (poor coordination)
May have a fruity odor coming from the mouth
Headache is normally present.
Drowsiness
Confused and disoriented
Intense thirst
May be angry and in a rage Eventual stupor or unconsciousness
Eventual stupor or unconsciousness
Urgent Care Tips: Ask diabetic assessment questions if the patient is conscious. Notify the physician stat. Obtain vitals and be prepared to perform blood glucose testing. Wait for the physician’s instructions. The physician may order a sugary substance (see the Field Smarts tool box) to help stabilize the patient’s blood sugar. Retest blood sugar according to the physician’s instructions. If unable to regulate, the patient may need to be transported to the ER.
Urgent Care Tips: If the patient is conscious, ask appropriate diabetic screening questions and alert the physician. Be prepared to perform blood glucose testing. If the patient is unconscious, notify the physician stat. Be prepared to administer insulin via injection or IV according to the physician’s instructions.
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F IEL D S M A R T S Urgent care centers usually stock emergency supplies of glucose that may be in the form of pastes, gels, or tablets and may be given sublingually (under the tongue) or bucally (between the gums and cheek) for rapid absorption. Diabetic patients should keep these supplies as well. If you are at the scene of an emergency and these items are unavailable, you may want to try giving the patient a sugary liquid such as orange juice, apple juice, or a sugary cola. Liquid forms of glucose are best when emergency items are unavailable because they are absorbed at a faster rate into the bloodstream than solids.
Head and Neck Injuries Head and neck injuries are very serious due to the risk of paralysis and possibly death. The majority of head and neck injuries are the result of automobile accidents, sports injuries, motorcycle accidents, and falls. Any injury to the brain caused by trauma is termed a traumatic brain injury. Typical head injuries include the following: ❖ Concussion: An injury in which the brain is jarred ❖ Brain contusion: A bruising of the brain that may cause some internal bleeding and swelling. Often caused by a skull fracture, but may also be caused by a severe jarring sensation, such as in shaken baby syndrome, or when a car stops abruptly. ❖ Skull fracture: An injury in which the skull cracks; may cause the edges of the skull to cut into the brain.
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❖ Hematoma: Bleeding in the brain that eventually clots. Symptoms are not always immediate and may be delayed for several weeks.
Heart Attack The medical term for heart attack is myocardial infarction. A myocardial infarction may be the result of atherosclerosis or a buildup of plaque in the coronary
FIGURE 35-16 A cervical collar is carefully applied when neck injuries are suspected.
arteries. The plaque can split away or snag onto the side of the vessel, causing a clot to form. The combination of the clot and plaque can trigger the arteries to become partially or completely occluded, restricting blood flow to the heart and causing the heart to eventually stop. Other conditions can also cause the heart to arrest, including arrhythmias and cardiomyopathy. Patients at the highest risk for heart attack include males, menopausal women, smokers, patients with a familial history of heart disease, and diabetics. Symptoms and signs of a heart attack include: Uncomfortable tightness or squeezing in the chest that may radiate to the arm, neck, or jaw (especially on the left side), shortness of breath, nausea and vomiting, ashened appearance, diaphoresis (excessive sweating), and dizziness. Urgent Care Tips: Immediately alert the physician and wheel the patient back to the cardiac bay. (Allowing the patient to walk back to the room could result in a depletion of existing oxygen stores.) Unbutton the patient’s shirt and place the patient in a semi-Fowler’s
E M R A P P L I C AT I O N When a patient is transported to the hospital due to an emergency, important information can be sent via computer to the ER before the patient even arrives. Pertinent data that should be sent electronically includes the progress notes and testing results from the current visit, the patient’s current medication list, a listing of drug allergies, patient history information,
and the results of previous testing that can be used for comparison studies. This network provides physicians in the ER with an opportunity to start formulating a game plan before the patient arrives, saving precious time and money by not duplicating tests that have already been performed.
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Head and cervical neck symptoms will vary depending on the severity and location of the injury, but may include severe head, neck, and back pain that radiates down to the shoulders, arms, or legs, tingling in or slight paralysis of the extremities, confusion, listlessness, and dilation of one or both pupils. Symptoms of head injuries may also include drainage coming from the eyes, ears, mouth, or nose. Lower injuries involving the spinal cord may cause paralysis, breathing difficulties, and a loss of bowel or bladder control. Spinal cord injuries (SCI) are very serious because any additional movement can cause significant damage to the already injured vertebrae and spinal cord. Patients that sustain traumatic head and spinal injuries are usually transported by the EMS to the nearest trauma center. There are those occasions in which the patient has few or no symptoms at the time of the injury but may have an exacerbation of symptoms days following the injury. The patient may not realize the seriousness of the injury and may seek the services of a family practitioner or urgent care center rather than a hospital. Urgent Care Tips: Alert the physician stat. Do not allow the patient to move. Obtain a head cervical collar and be prepared to assist the physician with head and neck immobilization (Figure 35-16). If the physician feels the injury is critical, the medical assistant may need to notify the EMS so that the patient can be transported by squad to the nearest emergency facility.
URGENT CARE AND EMERGENCY PROCEDURES
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F IEL D S M A R T S Today, aspirin is commonly prescribed to help prevent heart attack and stroke. Studies indicate that aspirin, a blood thinner, may also reduce the severity of heart attack if taken immediately when symptoms first occur, and that survival rates are better as a result. If an aspirin is taken during a heart emergency, it should be chewed up and then swallowed with lots of water so that it gets into the bloodstream quicker.
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position. Connect a cardiac monitor or ECG unit to the patient and apply the pulse oximeter. Prepare oxygen supplies but do not administer until ordered to do so by the physician. Monitor vitals, and make certain the crash tray and AED is accessible. Perform CPR, if necessary.
Poisonings Poisonings can be very serious and may progress into a respiratory or cardiac emergency. More than 90% of poisonings occur in the home and over 50% of poisonings occur among children under the age of six. Poisons can enter the body through one of four routes. Refer to Table 35-9 and Figure 35-17 for an in-depth look at poisons. Urgent Care Tips: Alert the physician as soon as possible and place the patient in the cardiac bay. Retrieve medications that induce vomiting, such as syrup of ipecac, but do not give unless ordered to do so by the
TABLE 35-9 Information on Poisons ROUTE
DEFINITION
SYMPTOMS
TYPES
FIRST AID
Ingestion Poison is taken (Figure 35-17a) in through the mouth, where it will eventually enter the digestive system.
Burning or swelling of the lips, mouth, tongue and throat May have discoloration of mouth Nausea, vomiting, and diarrhea may also be present.
Household products such as bleach, cleaners, and alcohol Garage products may include radiator fluid and oil or gasoline.
If at the scene, examine the mouth and remove any foreign bodies, powders, or tablets. Wipe the mouth out with a cloth. Do not induce vomiting and do not give any liquids without instructions from poison control. Call EMS if directed.
Inhalation Poison is (Figure 35-17b) inhaled through the nose and/or mouth.
Coughing, breathing difficulties, nausea/ vomiting, headache, and loss of consciousness
Dangerous fumes from household cleaners, carbon monoxide, and cyanide
If at the scene, minimize your risk and move the patient to fresh air. Start artificial breathing if the patient stops breathing.
Injected Poison is (Figure 35-17c) delivered into the circulatory system by needle or insect.
Edema, erythema, and pain at the injection site The patient may go into an anaphylactic reaction.
IV drugs, bites and stings from snakes and insects
If at the scene, remove the object if you can do so without causing greater harm. Get the patient to a hospital stat.
Absorption Poison is (Figure 35-17d) absorbed through the skin.
Itching, burning, erythema, and rash on the skin Nausea and vomiting may be present. The patient may go into shock.
Insecticides and poisons from plants
If at the scene, remove contaminated clothing, rinse for a minimum of 10 minutes. Shower with soap and water. Throw away contaminated clothes.
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Confusion
Heart Odor from mouth
Burns on and around mouth Vomiting
FIGURE 35-17c Poisoning through injection
Drain Cleaner Poison
FIGURE 35-17a Poisoning through ingestion
Confusion Hydrochloric acid Light-headedness
Irritation of skin
Poison gas
FIGURE 35-17d Poisoning through absorption
Irritation to airways Difficulty breathing
physician. If the patient brought the bottle that contained the poison, make certain that it is accessible for the physician. Have the poison control number handy in the event the physician needs to consult with a poison control specialist.
Seizures
FIGURE 35-17b Poisoning through inhalation
Seizures are sudden attacks that result from a malfunction of the brain. Seizures are normally not life threatening but may become life threatening if patients choke on vomit or injure themselves during the seizure, which is why seizures are listed here under lifethreatening disorders. There are two major types of seizures: petite mal seizures and grand mal seizures.
URGENT CARE AND EMERGENCY PROCEDURES
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F IEL D S M A R T S Patients should never be encouraged to vomit when they feel they have ingested a potential poison. This is because chemicals within the poison, such as acids or alkalis, may cause severe burns to the patient’s gastrointestinal tract during regurgitation. Patients should always be referred to the poison control center or EMS when calling about possible poisonings.
Petite Mal Seizure Petite mal seizures are also known as absence seizures. They are usually seen in children between the ages of 6 and 12. Symptoms include staring, blinking, and tasting movements made by the mouth. They usually only last 10 to 20 seconds and the patient rarely remembers anything about the seizure. First aid is usually not necessary for this type of seizure. Grand Mal Seizure Typically, a grand mal seizure starts with a loss of consciousness. The patient usually has a history of epilepsy or another brain disorder. The patient may initially become stiff and then start violently shaking. The skin may turn gray and the patient may lose both bladder and bowel control or even vomit
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during the episode. The episode may last 30 seconds to five minutes. Following the seizure, the patient may have a headache, appear confused, and generally feel very tired. Urgent Care Tips: Alert the physician and make the environment safe for the patient. Move anything that could fall on the patient and place a pillow or blanket under the patient’s head. Roll the patient on to the side to keep the patient from choking on fluids or vomit. If bystanders are in the vicinity, move them away from the patient. Once the seizure is concluded, move the patient to an area where the patient can rest out of the vicinity of bystanders. Place the patient into the recovery position and provide comfort measures. The physician may choose to activate the EMS if the patient is pregnant, diabetic, does not regain consciousness, has additional seizures, or receives serious injuries as a result of the seizure.
Shock Shock is a potentially fatal condition that can be brought on by disease, injury, decrease in circulation, and fluid loss. During shock, organs and tissues of the body receive an inadequate flow of blood, depriving the organs and tissues of oxygen. Various systems within the body react to the lack of perfusion and try to preserve the blood for the major organs. Table 35-10 illustrates what happens to various systems when shock occurs. If blood flow to the organs becomes compromised, the body will sacrifice blood flow to specific organs to
TABLE 35-10 The Effects of Shock on Various Body Systems BODY SYSTEM
WHAT OCCURS
Circulatory
The blood vessels constrict, heart rate increases, and blood pressure drops.
Intestinal
The bowel becomes anoxic causing tissue to become necrotic, which releases bacteria into the abdominal cavity. The patient becomes nauseated and vomiting starts.
Kidneys
Initially the kidneys are fine, but as the blood pressure starts to fall, the body tries to preserve its water volume by sending out hormones that cause the patient to retain fluid. The patient has scanty urination and excessive thirst as a result. The kidneys become unable to properly regulate the acid-base balance and other electrolytes.
Respiratory
Because the cells are starved for oxygen, the body will begin to hyperventilate, resulting in respiratory alkalosis.
Nervous system
The patient becomes very nervous, possibly combative, and eventually unconscious.
Skin
The skin becomes cold and clammy.
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❖ Neurogenic shock: Caused by dilation of blood vessels that may be secondary to brain injury or excessive deep spinal anesthesia ❖ Psychogenic shock: Caused by traumatic emotional factors such as grief and fear; usually not fatal ❖ Respiratory shock: Caused by a traumatic injury to the respiratory tract. There is an inadequate exchange of oxygen and CO2. ❖ Septic shock: Caused by a toxic substance accumulating in the bloodstream, as in toxic shock syndrome
help maintain blood supply to the organs most affected by hypoperfusion. Figure 35-18 illustrates perfusion order during cases of shock. Early symptoms of shock include a rapid, weak pulse and clammy skin. As shock progresses, symptoms progress to include confusion, chest pain, dyspnea, and eventually unconsciousness. There are eight types of shock: ❖ Anaphylactic shock: Caused by a severe allergic reaction to substances such as foods, medications, and insect stings or bites (described earlier in the chapter) ❖ Cardiogenic shock: Caused by acute myocardial ischemia resulting in a decrease of oxygen to cells ❖ Hypovolemic shock: Caused by excessive blood volume loss brought on by internal bleeding, external bleeding, severe burns, and severe dehydration ❖ Metabolic shock: Caused by an impairment in homeostatis such as acid-base balance changes during a diabetic emergency
When to Anticipate Shock Shock is most likely to occur following surgical procedures, during certain metabolic disorders, during severe infections, and following severely traumatic physical or emotional events. Urgent Care Tips: Notify the physician stat. Place the patient in the Trendelenburg position or in a supine position with the feet elevated. Loosen the patient’s
FIGURE 35-18 When blood volume diminishes, as in cases of shock, the body tries to compromise by sacrificing blood supply to the less-significant organs in order to preserve blood for the vital organs such as the heart and brain.
1
2
3
4
4. Blood flow to the brain is maintained at all costs.
3. Blood flow to the heart and lungs is maintained until shock is profound.
2. Blood flow to abdominal organs is sacrificed after skin if shock progresses.
1. Blood flow to skin is sacrificed early in shock.
URGENT CARE AND EMERGENCY PROCEDURES
clothing. Keep the patient warm and provide psychological support. Be prepared to administer oxygen, gather IV poles and IV solutions, crash cart, and AED. Monitor the patient for the ABCs of CPR.
Stroke or Cerebrovascular Accident (CVA) A stroke, brain attack, or cerebrovascular accident (CVA) are terms that refer to a blockage or bleeding within the blood vessels of the brain. Blockages may be caused by a thrombus (blood clot) or embolus (air bubble, foreign body, or detached blood clot) that makes its way from one part of the body (usually the heart) to the vessels within the brain. The location and size of the thrombus, as well as the amount of time that goes by before intervention is instituted, will greatly impact the patient’s disability status and recovery process. Blocked vessels can lead to ischemia (a loss of blood supply to the affected area) eventually resulting in an infarct (death of the involved brain tissue). Signs and symptoms of stroke usually come on rapidly and include facial asymmetry, one-sided paralysis, severe headache, slurred speech, dilated pupils, loss of bladder or bowel control, weakness or a lack of coordination, blurred vision, and dizziness. Patients who are at a higher risk for a CVA include African Americans, males, patients with hypertension, heart disease, or diabetes, patients with a history of Transischemic attacks (TIA) or mini-strokes, and patients that smoke. Symptoms of TIAs include headache, confusion, tinnitus, and personality changes. TIAs usually only last a few minutes and may be a predecessor to a stroke. Urgent Care Tips: Alert the physician stat and dispatch the EMS. The patient should be placed in the
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cardiac bay or equivalent and vitals should be performed. Have the patient lie very still. Monitor the patient and be prepared to perform CPR if necessary. In order to have the best chances of a full recovery, clot-busting drugs such as tissue plasminogen activator (tPA) should be administered within three hours from the onset of symptoms, making early transport to the hospital critical.
Syncope Episodes Syncope is a brief episode of unconsciousness or fainting. Fainting is not a disease but rather a symptom of an underlying condition or disease. It may be triggered by a variety of factors, including emotional stress, pain, pooling of the blood due to poor positioning of extremities, severe coughing episodes, and orthostatic hypotension (blood pressure that drops upon standing). It may also be related to heart and lung disorders, brain or neurological disorders, and certain medications such as antihypertensives, antidepressants, and diuretics. Causes for concern include: ❖ Syncope is in conjunction with a heart irregularity. ❖ There is a family history connected with sudden death following a syncope episode. ❖ The syncope episode occurs in combination with exercise. Urgent Care Tips: Alert the physician! Check the patient’s breathing and circulation status by going through the ABCs of CPR. Next, check for possible injuries. If head and neck injuries are involved, do not attempt to move the patient. If it appears that the
Vasovagal syncope episodes may occur as the result of traumatic news, observing a traumatic event, or anxiousness associated with an anticipated “painful procedure” such as an injection or blood draw. In anticipation of a stressful event, the body’s sympathetic nervous system sends out hormones that cause the heart to beat faster and the blood pressure to increase. Once the event is over, it may lead to a precipitous drop in blood pressure and heart rate, causing the patient to faint. These episodes are usually benign and typically occur when the patient is standing, but may on occasion occur during
sitting. Prodromal symptoms may include dizziness, pallor, perspiration, a warm sensation, nausea, and a visual “grayout.” Prolonged syncope may lead to seizures. If the patient appears to be nervous during a blood draw or has a history of vasovagal episodes, have the patient lie in a supine position during the procedure. Observe the patient closely both during and following the procedure. If the patient exhibits any prodromal signs, remove the needle and have the patient cross the legs together, squeezing tightly while bending the head toward the ground, or place the patient in the Trendelenburg position.
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CR ITI C A L TH I N K I N G C H AL LEN G E After drawing the patient’s blood you notice that the patient is pale. You ask how the patient feels; the patient tells you that he is fine and needs to leave because he is late for work. 1. What vital signs should you perform to help you get a better grasp of the patient’s current status? 2. What results from the vitals would alert you that the patient is not ready for release? 3. What steps should you take to help prevent the patient from fainting?
patient can be safely positioned into the Trendelenburg position or equivalent, do so immediately. Check the patient’s vital signs and have someone gather IV poles, IV solution, crash cart, and AED just in case they are needed. Place a cool, wet cloth on the patient’s head and continue to monitor.
Temperature-Related Emergencies Patients do not typically go the urgent care during a temperature-related emergency but may call the office inquiring about symptoms or may stop on the way to the hospital because symptoms worsen. Because certain temperature-related emergencies can be life threatening, they are listed under life-threatening emergencies. Homeostasis refers to the body’s maintenance of a consistent internal environment. The nervous system, respiratory system, skin, and excretory system all work together to keep our bodies functioning properly. Temperature is a body process that must stay within a certain range or serious complications will result. Heat-Related Emergencies There are three conditions that are brought on by heat exposure. The first is heat cramps. Heat cramps are usually confined to the abdomen and legs and result from a combination of factors, including elevated temperature, loss of fluids, and a loss of salt from the body. Heat cramps occur when the body becomes overheated and are the least serious of all of the heat-related emergencies. Heat exhaustion most commonly occurs as the result of exposure to excessive heat while working or
exercising. The victim sweats and loses large volumes of water and salts. The blood capillaries rise to the surface of the skin, where the blood pools to assist in the cooling process. This whole process creates a mild form of shock, which may lead to heat stroke if not remedied. Heat stroke occurs when the body is either unable to cool itself down due to dehydration, physiological conditions, or a progression of heat exhaustion factors that go untreated. This condition is most common on very hot days and is sometimes referred to as “sun stroke,” although the person does not have to be in the sun to have heat stroke. Seniors and infants are most susceptible to heat stroke, but patients with lung, heart, and kidney disease are also susceptible. Heat stroke is a life-threatening emergency and the EMS should be activated right away. Refer to Table 35-11 for a list of symptoms and first aid tips for each type of heat-related emergency. Cold-Related Emergencies Frostbite is a local injury of the skin due to freezing or subfreezing conditions. Factors that can increase the risk of frostbite include wet gloves and socks, high wind conditions, and prolonged exposure to cold temperatures. The nose, toes, fingers, face, and ears are the most vulnerable sites to frostbite. Frostbite is not a life-threatening condition but is under life-threatening conditions because it is categorized with hypothermia. Symptoms of frostbite include skin that feels frozen or hard, a white, waxy appearance, swelling, and blisters. The skin may be red, purple, or mottled. Proper treatment includes removal of the victim from the cold environment, removal of cold, wet clothing, and warming the affected part by natural means such as body-to-body contact and blankets. Avoid rubbing, massaging, or quick heat treatments with hot water or heating pads, as this may cause further injury. Hypothermia is another type of cold-related emergency that affects the body’s core temperature. Normal body temperature is around 98.6°F (37°C). Hypothermia victims usually have body temperatures that fall below 95°F (35°C) and may be at serious risk of dying without medical intervention, which is why hypothermia is listed under life-threatening conditions. Factors that make persons more susceptible to hypothermia include age (the very old and very young), prolonged exposure to cold and wet environments, various medications, and alcohol and drug use. Symptoms include cold skin, shivering, dizziness, mental impairment, a decrease in motor function, and a very rigid posture.
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TABLE 35-11 Symptoms and First Aid Tips for Heat-Related Emergencies CONDITION
SYMPTOMS
FIRST AID TIPS
Heat cramps
Abdominal and leg cramps, general weakness or fatigue, heavy sweating, possible dizziness or fainting
Move the patient to a cool place to rest for a while. The patient should stretch the affected muscles and drink plenty of water.
Heat exhaustion
General weakness, rapid and shallow respirations, weak pulse, cool clammy skin, diaphoresis, may be unresponsive
Immediately move the patient to a cool place. The patient should stop activity and drink liquids slowly. Apply cool wet compresses and monitor the patient carefully.
Heat stroke
A temperature of 104°F (40°C) or higher, general weakness, initial deep respirations that change to shallow respirations, pulse may start out as rapid and strong but may change to rapid and weak, dry hot skin, very little or no sweating, dilated pupils, muscle twitching, convulsions or unconsciousness
Perform CPR if necessary and move to a cool area if possible. Remove the victim’s clothing and place a cool wet sheet over the victim or lightly spray the victim with a garden hose. Elevate the head and shoulders and notify the EMS as soon as possible.
Respiration and pulse rates will slow down and eventually stop, so victims should be monitored for the ABCs of CPR. Other treatment measures for hypothermia are similar to the management of frostbite. Do not give hypothermic victims anything by mouth. Activate the EMS as soon as possible.
Non-Life-Threatening Emergencies The majority of patients seen in an urgent care facility are seen for non-life-threatening disorders; however, careful screening is still very important for determining levels of priority. The medical assistant will need to consider the following factors when working with patients with non-life-threatening disorders: 1. The possible complications or damages that may incur from a delay in treatment 2. The patient’s discomfort level (both physical and emotional) 3. The environment and atmosphere of the reception area The following are examples of non-life-threatening conditions that may fall into one of the three categories listed above.
Bleeding Emergencies (Non-Life-Threatening) The majority of bleeding emergencies in the office will be on a smaller scale and include lacerations and other
open wounds. Even though these patients may not be in danger of hemorrhaging to death, a smaller bleeding emergency can be quite distressful to the patient, the patient’s family, and other families sitting in the reception area. The medical assistant should also consider the sanitary conditions of the reception area. If the patient is dripping blood on the floor or on the furniture in the reception room, the environment of the room is now unsanitary and unsafe. Patients who are bleeding through bandages and towels should be escorted back to the triage area immediately following patients with life-threatening conditions.
Nosebleeds Patients may lose large volumes of blood during a nosebleed. There are two types of nosebleeds: ❖ Anterior nosebleed: These occur in the lower part of the septum, which is a highly vascular area. Anterior nosebleeds usually just involve one side. They may occur as the result of a minor injury. Anterior nosebleeds are also common in dry climates or during the winter when a furnace is running. ❖ Posterior nosebleed: These are rarer and more dangerous than anterior nosebleeds, usually occurring higher and deeper in the nasal cavity. These types of nosebleeds occur more often in older patients, patients with facial or nasal injuries, and in patients with hypertension.
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PAT I E N T T U T O R To help prevent nosebleeds, use a dehumidifier during the winter months, and lubricate the interior of the nose with an ointment or cream. Avoid picking the nose or blowing really hard. Sleep with the head elevated. When a nosebleed occurs, remain calm and avoid tilting the head back, as this will cause the blood to run down the back of the throat. Try pinching the soft tissue of the nose with the thumb on one side and the index finger on the
The Patient Tutor tool box on this page lists prevention and first aid tips that may be given to patients who are prone to nosebleeds.
Burns Burns are very concerning because of the complications that may arise as a result of a burn. Some patients may not understand the extent of their burns and go to an urgent care center or physician’s office instead of going directly to the emergency room. The following criteria may be used to assess the seriousness of a burn. Patients that exhibit any of the signs or symptoms below or match the following criteria are usually sent on to the emergency room. 1. Patients with breathing problems (be prepared to assist with the breathing emergency) 2. Patients with burns in certain locations (burns located on the head, neck, hands, feet, and genitals are considered severe) 3. Patients with multiple burns or burns that cover a large surface area 4. Patients of certain ages (the pediatric patient and older adults are more susceptible to complications from burns) 5. All full thickness burns are considered critical burns. Types of Burns Refer to Table 35-12 describing how burns are classified. Another factor that helps to assess the severity of a burn is the percentage of body surface area that is involved in the burn. The Rule of Nines formula is used most often in the field by medics who need to determine very quickly how much of the body is affected. The following is a general breakdown of how this formula is used in adults:
opposite side, pressing against the bones of the face. Pinch closed for five minutes (you may breathe through your mouth). The head should always remain elevated; do not lay flat. Place an ice bag filled with crushed ice above the area in which you are pinching. This will constrict blood vessels in the area, thus decreasing the amount of blood loss. If bleeding does not slow down or stop, activate the EMS.
Each arm Face Each leg Back of head Upper and lower back Genitals Chest and abdomen
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9% 4 ⁄2% 18% 41⁄2% 18% 1% 18% 1
Figure 35-19 illustrates the Rule of Nines by assigning a skin surface percentage to eleven different body parts. When the major surface areas are tallied together, it totals 99%. The remaining 1% is assigned to the genitals. The Rule of Nines does not apply to infants and children because of differences in head and body proportions; however, there are charts that can assist in tallying affected areas in their age groups as well. Refer to Figure 35-20 for a breakdown of body surface percentages in babies and children. Infection is a big concern for patients who sustain burns. Urgent Care Tips: The medical assistant should use all sterile supplies when working with burn patients. Comfort measures should also be considered. The medical assistant may apply sterile saline compresses to the burn to provide some comfort to the patient. Retrieve any burn supplies that the physician may need, such as sterile bandaging supplies, 4x4s, and burn ointments such as silver sulfadiazine or Silvadene ointment.
Eye Injuries Severe eye injuries or chemical burns to the eyes are usually considered emergencies as well, because damage to the eye can occur very quickly and a delay in treatment may lead to serious eye damage or blindness. Urgent Care Tips: Patients that possess severe eye injuries, such as chemical burns or foreign bodies in the eye, should be assessed right away. Chemical burns
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TABLE 35-12 Types of Burns TYPES OF BURNS
DEGREES OF BURNS
Thermal burn: Caused by heat, such as a hot surface or flames General first aid: Cool the burn by pouring cool sterile saline or water over the site to provide comfort for the patient. If the burn is minor and does not cover a large area, cover the burn with a sterile dressing; otherwise, cover the burn with a sheet.
Superficial burns (formally known as 1st degree burns): Involves the first layer of the skin Symptoms: Reddening of the skin, warmth and pain; skin remains intact
A superficial burn (Courtesy of the Phoenix Society of Burn Survivors, Inc.)
Chemical burn: Caused by contact with acids or alkalis General first aid: Clothes should be removed and the area should be flooded with water for a minimum of 15 minutes. Dry chemicals should be brushed off before flushing the patient’s skin. Some dry chemicals are activated by water. Cover the burn with a sterile dressing. The burn hould be assessed by a physician. Chemical burn to the eye: Should be flushed with water from the inside to the outside for 10 to 15 minutes
Partial thickness burns (formally known as 2nd degree burns): Burns that extend into the dermis or second layer of the skin Symptoms: Skin may appear white to pink; may have some fluid loss and blisters; mild to moderate pain
Electrical burn: Occurs after contact with electrical wiring (can also be caused by a lightning strike); hard to assess outwardly; could be internal injuries that are not visible to the naked eye General first aid: Make sure the electrical source has been shut down prior to applying first aid (never touch an electrical wire!); administer CPR if necessary and call the EMS.
Full thickness burns (formally known as 3rd and 4th degree burns): Involves all three layers of the skin including fat and muscle tissue, which may decrease the motility and function A full thickness burn of the affected area. Nerve (Courtesy of the Phoenix endings are usually destroy- Society of Burn Survivors, ed, so the patient may have Inc.) no pain. Symptoms: The surface of the burn may have a hardened appearance that appears pearly white and leathery. Greatly damaged tissue has a charcoal appearance and underlying tissue is usually visible.
are normally irrigated with tepid water or saline for several minutes to help remove the chemicals. If the eye has been injured and it will be a few minutes before the physician is available, the physician may want the medical assistant to cover both of the patient’s eyes to prevent further damage to the affected eye (if the unaffected eye moves to look at someone or something, the affected eye will follow suit, causing more damage).
A partial thickness burn (Courtesy of the Phoenix Society of Burn Survivors, Inc.)
Obtain the eye tray, numbing drops, dye, ultraviolet light, and ophthalmoscope. Some practices may want the medical assistant to perform a visual acuity test to screen for vision damage.
Mentally or Emotionally Distressed Patients The emotional or mental state of the patient will also need to be considered. If a patient appears highly
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Front
41/2%
(A)
A 1
18%
41/2%
2
41/2%
2
13
1 1% 9%
Back
2 1
1
1 2
11/2 1
9%
B
B
C
C
1
1
2
13
1
1 /2
2
11/2
(B)
(B)
(C)
(C)
1
1
1 /2
Area
Birth
1 yr
1 /2 5 yr
A (head) B (one thigh) C (one leg)
19 6 1/2 6
17 7 1/2 6
14 9 6
41/2%
A
(A)
1
1
18%
41/2%
41/2%
13
2
9%
9%
2
11/2
13
2
2
11/2
11/2
1 1
21/2
21/2
(B)
(B)
1
1 /4
B
1 /4
B
11/4
FIGURE 35-19 The Rule of Nines is used to estimate the percentage of body surface area burned (adult example). C
agitated and is very vocal in the reception area, this can be quite distressing to the families waiting in the area. Safety is also a concern in these cases because mentally or emotionally unstable patients may pose a physical threat to themselves, office personnel, or other patients sitting in the reception area. Urgent Care Tips: Alert the physician of the patient’s mental or emotional state and be prepared to give the physician a list of local mental health centers. Assist the patient to an examination room as soon as possible and encourage the patient to discuss fears or concerns until the physician takes over. If the patient starts making threats to the physician or other staff members, be prepared to call both the police and EMS for professional intervention.
3
1 /4
C
(C)
3
3
1 /4
Area A (head) B (one thigh) C (one leg)
(C)
3
1 /4
1 /4
10 yr
15 yr
11 8 1/2 6
9 9 6 1/2
Adult 8 9 7
FIGURE 35-20 The Lund and Browder chart is used for estimating the extent of burns in infants and children.
Musculoskeletal Injuries Fractures and other limb injuries are commonly seen in patients who use urgent care services. These types of injuries are non-life-threatening but may be very uncomfortable to the patient. Patients with musculo-
URGENT CARE AND EMERGENCY PROCEDURES
skeletal injuries are usually in a great deal of pain and discomfort. It is difficult to determine the seriousness of the injury without the aid of x-rays. Types of musculoskeletal injuries include: ❖ Fracture: A fracture is another term for a broken bone. Fractures often involve injury to surrounding tissue such as the tendons, ligaments, and nerves. Types of fractures can be found in Chapter 21. There usually is a great deal of pain and swelling involved with fracture injuries. ❖ Strain: A strain results from overuse or exertion of the affected muscle. There usually is no swelling, but the patient may have quite a bit of pain upon movement. ❖ Sprain: A sprain results from a twisting or wrenching of a joint, which causes the attached ligament to stretch or tear, causing bleeding within the tissue. The bone is usually not affected, but the patient may experience a great deal of pain and swelling. ❖ Dislocation: This is a separation of a bone from its normal place of attachment or position within a joint. The patient is usually in a great deal of pain and discomfort and there may be damage to surrounding structures such as the ligaments, blood vessels, nerves, and soft tissue. Whether in the office or at the site of the accident, all musculoskeletal injuries should be treated as possible fractures. Urgent Care Tips: Patients with lower musculoskeletal injuries should be transported to the clinical area in a wheelchair. Patients with all types of musculoskeletal injuries are normally placed in a special procedure room that has casting and splinting supplies. The affected limb should be immobilized and elevated and a cold pack should be placed over the site of the injury to help reduce current swelling and prevent future swelling. Musculoskeletal injuries will usually require x-rays, and the medical assistant may be responsible for assisting the physician with splinting or casting. Prior to and following the splinting of an injured limb, the provider or the medical assistant should perform the following CSM mnemonic to check circulation of the limb and to check for possible nerve damage. ❖ “C” for circulation: Check the distal pulse of the limb to make certain that blood is reaching below the point of injury, and check for capillary filling of the nail bed. A change in color from the affected side verses the unaffected side could indicate an impairment in circulation.
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911
❖ “S” for sensation: Check the temperature of the affected limb with the opposite limb and ask the patient about overall feeling and pain status. Paresthesia (tingling or burning sensation) or anesthesia (a lack of feeling or no feeling) could indicate nerve entrapment or damage. ❖ “M” for movement: Check to make certain that the patient can move the digits on the affected limb. An interruption of blood flow or a problem with how the extremity is positioned could cause additional damage to the patient, so the CSM findings should be shared with the physician as soon as they are obtained. The Purpose of Splinting Splinting is a procedure that is performed to prevent further damage or injury to the affected extremity. Uncontrolled movement to a fractured limb could cause further damage to the soft tissue, blood vessels, or nerves surrounding the fracture as well as causing extensive pain to the victim. Procedure for Splinting Procedures used for splinting will vary according to the materials that are available. Many first aid kits come complete with commercial splints. These splints are usually very easy to apply and come with a set of detailed instructions. If a commercial splint is not available, items such as magazines, books, pieces of wood, and pillows may be used temporarily. Also, items to attach the splint to, such as string, strips of sheet material, or roller gauze, will be needed. Sometimes a triangular bandage and gauze (Figure 35-21) can be used to splint a limb when no splints are available. Steps for applying a non-commercial splint are listed:
FIGURE 35-21 A sling and swathe can be used to immobilize an arm when a splint is not available.
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1. Measure the splint and make any necessary adjustments. 2. Pad the splint, if possible, so that it is more comfortable for the victim. 3. Carefully stabilize the extremity by manually immobilizing the joint above and below the injury. 4. Assess the limb, using the CSM mnemonic once again before applying the splint. 5. Apply the splint and secure the limb by immobilizing the joint both above and below the injured site. If splinting a hand or foot, splint to accommodate movement; otherwise, splint the limb in the position it was found. 6. Once splint has been applied, reassess the limb for circulation, sensation, and movement. 7. Apply ice to the affected site. 8. As per the physician’s orders, send the patient to the emergency room or give the patient homecare instructions. Refer to Procedure 35-3 for a complete procedure on applying a professional splint.
affected area with an ace bandage, and elevating the extremity. Some physicians now encourage the MICE mnemonic, which incorporates some back and forth movements with ice while sitting. This is especially true for certain types of sports injuries. The second 24 hours may involve changes in treatment from the first 24 hours. These changes in treatment are designed to promote circulation and healing and may exchange cold therapy with heat therapy or may combine the two. Always check with the physician for clarification. Chapter 21, the orthopedic chapter, lists the exact steps for applying heat and cold therapy. Figure 35-22 illustrates various bandaging techniques used for traumatic wounds.
FIGURE 35-22a A recurrent bandage may be used on the head.
Wounds The majority of wounds that are seen in an urgent care center are not the type of life-threatening wounds that are seen in an emergency room, but may involve bleeding and a great deal of pain. There are two major types of wounds: closed and opened. Closed Wounds Closed wounds include bruises, hematomas, strains, and sprains. In general, the treatment for all soft tissue injuries is the same and uses the mnemonics RICE and MICE. Refer to Table 35-13 for a description of both. The focus for the first 24 hours following an injury is to reduce swelling and inflammation; therefore, the RICE treatment is usually followed, which entails resting the affected area, applying ice, compressing the
FIGURE 35-22b A roller bandage may be used to cover a head wound.
TABLE 35-13 RICE and MICE Descriptions RICE
MICE
R = Rest
M = Movement or motion
I = Ice
I = Ice, heat, or both
C = Compression (ace bandage)
C = Compression (ace bandage)
E = Elevation
E = Elevation 1
2
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1
2
3
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4
FIGURE 35-22c A triangular bandage may also be used to cover a head wound.
1
2
FIGURE 35-22d A cravat may be used to hold a dressing in place on the head. 1
2
3
FIGURE 35-22g A spiral bandage may be used to cover an extremity.
3 1
2
FIGURE 35-22e A double cravat may be used to cover and secure an ear injury. 1
1
2
FIGURE 35-22f A figure eight bandage is used to immobilize a joint.
3
2
FIGURE 35-22h A reverse spiral turn may be used when extra padding is essential.
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Open Wounds Abrasions (Figure 35-23) are superficial scrapes that may be very painful. These types of injuries are usually not serious and can be treated at home unless gravel and dirt are embedded within the wound. Usual home care involves gentle cleansing of the area, application of an OTC antibiotic cream, and a dressing to keep the site clean. Reinjury, which occurs quite often with young children, creates an increased risk of infection. Incisions (Figure 35-24) are cuts in the skin made from items such as sharp instruments or glass. Incisions may be deliberate, as in surgical incisions, or may be accidental. Deeper incisions may involve a great deal of bleeding and can become easily infected. These types of incisions should be closed within six hours of the injury by one of the following methods: adhesive skin closures, suturing, or surgical adhesives. Treat-
ment for minor incisions includes gentle cleansing to the area and the application of a dressing. Check to see when the patient’s last tetanus shot was performed. If it was more than 10 years prior, the patient will probably need to have a tetanus booster. Lacerations (Figure 35-25) are different from incisions because they are usually irregularly shaped cuts with jagged edges. They may also appear as tears. Bleeding is usually very heavy and the patients often need sutures. If bleeding is minimal, this may create more risk of infection because bleeding promotes cleansing. Treatment usually involves cleansing of the wound and possible wound closure. Check to see when the patient’s last tetanus shot was performed. Punctures (Figure 35-26) are usually caused by objects such as sticks, pins, nails, or pieces of glass that penetrate the skin, leaving a hole in the skin.
FIGURE 35-23 An example of an abrasion
FIGURE 35-25 An example of a laceration
FIGURE 35-24 An example of an incision
FIGURE 35-26 An example of a puncture
URGENT CARE AND EMERGENCY PROCEDURES
They may be superficial or deep. There is usually little bleeding with superficial punctures, so these kinds of wounds are also very susceptible to infection. Superficial wounds should be cleansed and bandaged and the patient should be encouraged to watch for signs
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of infection. Deeper wounds should be professionally examined, cleaned, and x-rayed. The patient’s tetanus status should be checked. To learn how to properly clean and dress open wounds, refer to Chapter 24.
PROCEDURE 35-1 Apply First Responder Principles during an Emergency to an Adult Objective: To properly assess a victim at the scene of an emergency and to appropriately respond by providing the necessary first aid measures until the physician or EMS arrives on the scene.
Equipment/Supplies: ❖ First aid kit ❖ AED ❖ One-way valve mask PROCEDURAL STEPS
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RATIONALE
1. If outside of the office, determine the safety of the scene. Avoid scenes with oncoming traffic and scenes where live wires may still have electricity going through them. Pay attention to gassy odors.
Making certain that the scene is safe will prevent you from becoming a victim yourself.
2. Apply appropriate PPE items such as gloves, gown, masks, or goggles.
It is important to protect yourself from potentially infectious body fluids that may cause disease.
3. Establish unresponsiveness of the victim and rate the victim’s consciousness using the AVPU scale. Check for a MedicAlert product on the victim.
You must determine the victim’s level of responsiveness before knowing how to proceed with the victim. Checking for a MedicAlert bracelet may provide important clues.
4. Alert the physician and coworkers right away and have someone call the EMS.
Early medical intervention is essential for a good outcome.
5. “A of ABCDDR”: Open the airway using the head tilt/chin lift procedure for victims with no signs of head or neck injury and use the jaw thrust technique for victims with suspected head and neck injuries.
Opening the airway pushes the tongue away from the back of the throat and could be all that is necessary to stimulate breathing. Using the correct opening technique helps to avoid further injury in cases of head and neck trauma.
6. “B of ABCDDR”: Look, listen, and feel for signs of breathing. If no breathing is present, deliver two effective breaths (Figure 35-27).
It is important to get oxygen into the victim as soon as possible.
FIGURE 35-27 The medical assistant gives the patient ventilations to help restore the patient’s breathing.
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RATIONALE
PROCEDURAL STEPS 7. “C of ABCDDR”: Check the carotid pulse and for other signs of circulation. If you do not have an AED, correctly provide compressions and ventilations (five sets of 30 compressions to two ventilations) for two minutes. Recheck the pulse after the first set and every few minutes thereafter. Continue until the EMS arrives or the victim regains respiration and a pulse.
If the victim does not have a pulse, it is important to provide compressions to push the oxygen that you just put into the victim around the body.
8. “D of ABCDDR”: If there is no pulse and you have an AED, apply the AED pads (Figure 35-28), and follow the instructions listed on the AED, including providing compressions as needed (Figure 35-29).
Early defibrillation is essential for a good outcome.
9. “D of ABCDDR”: Check for disabilities (Figure 35-30). Perform a head-to-toe evaluation looking for other signs of disability including a DOTS assessment (deformities, open injuries, tenderness, or swelling).
Once you have taken care of any breathing and circulation concerns, you want to check for other types of disabilities. The victim may have a bleeding crisis that needs to be managed or a fractured limb. You will not know until you do a head-to-toe evaluation on the victim. Remember if the victim has head or neck injuries, do not move the victim.
10. “R of ABCDDR”: Appropriately respond to the victim’s condition or injuries. Control bleeding and splint any limbs that need to be immobilized.
It is important to apply appropriate first aid to other injuries to help minimize complications.
11. Assess the victim’s vital signs and continue to monitor the victim. 12. Report findings to the physician or EMS personnel.
The quicker that the physician or EMS team have assessment data, the quicker they can treat the victim.
13. Dispose of biohazardous wastes into the biohazard trash can.
FIGURE 35-30 Once lung and
FIGURE 35-28 Example
FIGURE 35-29 Com-
of where the AED pads should go on the patient’s chest
pressions help to circulate the blood around the body.
heart function is restored, the medical assistant will check the patient for additional disabilities.
URGENT CARE AND EMERGENCY PROCEDURES
PROCEDURAL STEPS
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RATIONALE
14. Wash your hands. 15. Document findings in the patient’s chart if working in the urgent care center or a physician’s office.
Documentation is extremely important, especially in an emergency situation. Good documentation proves that you followed the steps that were necessary to assist the victim.
DOCUMENTATION EXAMPLE:
11-15-XX 2:00 p.m.
Patient collapsed in reception area. Applied the ABC’s of CPR and performed two sets of CPR until Ryan arrived with the AED. Hooked AED to patient and performed an analysis. Two shocks delivered following the first analysis. Patient regained consciousness after second shock. Went on to perform a DOT’s assessment. Patient did not appear to have any other injuries. Patient placed in recovery position and physician took over shortly thereafter. D. Hall, CMA (AAMA)
PROCEDURE 35-2 Control Bleeding in the Medical Office Objective: To properly apply basic first aid steps to control bleeding.
Equipment/Supplies: ❖ Several sterile 4x4s ❖ Roller gauze PROCEDURAL STEPS
RATIONALE
1. Identify the patient using two identifiers, identify yourself, and observe the area to determine the extent of the bleeding. 2. Apply PPE. If the area is already bandaged and bleeding is seeping through the other bandage, apply 4x4s over the top of the existing bandage. If no bandage is present, apply sterile/clean 4x4s over the bleeding wound and apply pressure (Figure 35-31).
Removing the existing bandage before the blood is clotted could interrupt the clotting process.
3. While still applying direct pressure to the site, elevate the arm above the level of the heart (Figure 35-32).
Elevating the arm decreases the amount of blood flowing to the area.
4. Apply direct pressure to the artery between the point of attachment and the site of the injury (Figure 35-33). Compress the artery against the bony surface of the limb. (Use the brachial artery for the upper limbs and the femoral artery for the lower limbs.) Continue to apply direct pressure and elevate the extremity.
Applying direct pressure to the artery above the site of injury slows down the bleeding process due to constriction of the artery.
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FIGURE 35-31 Apply direct
FIGURE 35-32 Elevate the arm
pressure using a sterile bandage whenever possible.
above the level of the heart.
PROCEDURAL STEPS
FIGURE 35-33 Apply pressure to the nearest pressure point.
RATIONALE
5. If bleeding is still uncontrolled, a tourniquet should be applied. The physician should apply the tourniquet just above the affected area. Once applied, the tourniquet should not be loosened. Attach a note stating when the tourniquet was applied.
Tying a tourniquet just above the affected area will stop the bleeding, but may also promote major tissue damage to all the tissue located inferior to the site where the tourniquet is attached. This is why the physician should apply it. Indicating the time will alert hospital personnel to how long the tourniquet has been on so that they may act accordingly.
6. Treat the patient for shock and help the patient to remain calm while waiting for the EMS. Continue to monitor the patient for breathing and heart function.
Patients that lose large amounts of blood are candidates for shock. You must continually monitor the victim until the EMS arrives.
7. Document the incident. Dispose of soiled bandages in the biohazarous trash and clean and disinfect the area.
Documentation is necessary for legal purposes.
DOCUMENTATION EXAMPLE:
12-12-XX 09:25 a.m.
Pt. entered the urgent care with a towel saturated with blood wrapped around his L. wrist. “Sliced wrist while using a ban saw.” Escorted pt. immediately to the treatment room. Alerted physician. Towels were removed. Pressure bandage applied by patient was saturated with blood. Applied several 4x4s over the existing pressure bandage and elevated the arm above the level of the heart. While continuing to apply pressure to the site, used other hand to gently compress the brachial artery just above the elbow. Approximately ten minutes later, the physician instructed me to release my fingers that were compressing the artery and to remove the dressing and bandages. The bleeding appeared to be under control. Set the pt. up for a laceration repair per Dr. DiIullo. Physician took over the management of the wound from that point. Samantha Keir, CMA (AAMA)
URGENT CARE AND EMERGENCY PROCEDURES
❖
PROCEDURE 35-3 Splint an Arm Objective: To appropriately splint a patient’s arm who has a suspected fracture.
Equipment/Supplies: ❖ Splint
❖ Sling (if applicable)
PROCEDURAL STEPS
RATIONALE
1. Gather supplies and wash your hands 2. Identify the patient using two identifiers, identify yourself, and explain the procedure. 3. Follow the steps on the commercial splint for preparing the splint.
Each commercial splint is different, so you will need to follow the instructions on the packing to apply the splint.
4. Place the arm in the position that will be used for splinting (Figure 35-34). Be sure to stabilize the injured area by stabilizing the joint above and below the injury.
Stabilizing the joints above and below the injury will secure the injured site to prevent further injury.
5. Check the pulse point distal to the injury.
You need to determine if the new position is causing any obstruction to the blood flow.
6. Check for sensation and movement while the arm is in the splint position.
A lack of sensation or movement could indicate a nerve injury.
7. Apply the splint following the manufacturer’s instructions (Figure 35-35). If arm is to be totally immobilized, place the arm with the splint in a sling as well.
A sling will keep the arm stationary in one position.
8. Check distal pulse point, sensation, and movement after applying the splint (Figure 35-36).
Once the splint is on, circulation and nerve reflexes may be altered.
9. Apply ice to help reduce swelling.
Applying ice will help to decrease the swelling.
10. Wash your hands. 11. Document the procedure.
FIGURE 35-34 Place the arm in the appropriate position for splinting.
Documentation is necessary for legal purposes.
FIGURE 35-35 Apply the splint, following the manufacturer’s instructions.
FIGURE 35-36 Check the distal pulse point, sensation, and movement after applying the splint. continues
919
920
❖
CHAPTER 35
continued
DOCUMENTATION EXAMPLE:
05-14-XX 1230
Pt. entered the office during the lunch session. Dr. Woo stepped out for lunch and was not available when the pt. first arrived. Pt. fell off of his porch hitting his R. forearm on the grill. + tenderness, + swelling, –discoloration. Pt. had good strong pulse, movement, and sensation prior to splinting. Splinted R. forearm with commercial air splint and placed arm in a sling. Checked circulation, sensation, and movement once again after splinting. Good strong pulse, color was slightly pink, and temperature was warm. Pt. still able to move fingers. Applied ice and waited for Dr. Woo to return. Dr. Woo returned at 1300 and took over the management of the pt. Martin Ford, RMA
PROCEDURE 35-4 Treat the Patient for Shock Objective: To appropriately detect the signs of shock and respond accordingly.
Equipment/Supplies: ❖ Pillows ❖ Sheets/blanket PROCEDURAL STEPS
RATIONALE
1. Recognize that the patient may be going into shock and take the patient’s vital signs. Symptoms of shock include an increase in pulse, respiration, pale, cool, clammy skin, and restlessness.
The heart rate and respiration rate increases because of the lack of blood flow throughout the body.
2. Alert the physician or activate the EMS.
The more quickly the patient can get help the better the chances are for a full recovery.
3. Elevate the patient’s legs. You may use pillows or blankets if the exam table does not have a mechanism to elevate the legs (Figure 35-37).
Elevating the legs will help the blood to circulate back toward the brain.
4. Place a sheet or blanket over the patient to keep the patient warm.
Patients in shock are usually cold due to the decrease of blood supply.
5. Monitor the patient’s airway, breathing, and circulation.
FIGURE 35-37 Elevating the Patients experiencpatient’s legs will help the blood to ing shock symptoms flow back down toward the brain. may slip into respiratory or circulatory arrest. It is important to monitor the patient until help arrives.
6. Keep the patient calm and reassure the patient that help is on the way.
This may help delay unconsciousness.
7. Document the event and treatment.
Documentation is necessary for legal purposes.
URGENT CARE AND EMERGENCY PROCEDURES
❖
921
DOCUMENTATION EXAMPLE:
02-16-xx 1800
Pt. entered the urgent care after being in a car accident. While taking pt.’s vitals I noticed that pt. started sweating profusely. Skin was clammy and cool. Vitals: BP: 88/40, P 106, R 28. Alerted physician STAT. Treated pt. for shock by elevating pt’s legs and placing a blanket over pt. Dr. Legg had EMS dispatched. Pt. transported to hospital @ 1825. Rosa Garcia, RMA
Chapter Summary The medical assistant must have a thorough knowledge of emergency procedures before working in a physician’s office or urgent care center. Emergencies can occur at any time and office personnel must be ready to respond in an appropriate manner. Medical office staff members should practice what their roles would be during an office emergency so that when emergencies occur, everyone is prepared. All medical assistants should take a professional CPR and first aid class before entering an externship. Remember that every minute counts in an emergency, so medical assistants should prepare and practice so that they will be ready when emergencies do strike.
FIELD APPLICATION CHALLENGE The urgent care center is really busy tonight. Four patients just entered the reception room within five minutes of each other. All the regular examination rooms are full. One patient burned her arm on a hot pot and appears to be in quite a bit of discomfort. One patient is complaining of intense abdominal pain that came on very quickly, and another patient cut his foot on a piece of broken glass and is bleeding through the towel. The last patient fainted while at school today but is conscious now; his mother wants to have him evaluated.
1. List the order in which you would see each patient and explain why you would see the patients in the order you listed. 2. In which rooms would you place each patient? 3. Which patient(s) may need to transported to the hospital?
Chapter Assessment 1. What is the first step of a first responder? a. Open the airway b. Establish responsiveness c. Call for help d. Determine scene safety
3. What is the third step to control bleeding? a. Elevation b. Tourniquet c. Direct pressure d. Pressure point
2. You should use the jaw thrust maneuver when working with: a. victims with suspected neck injuries. b. infants. c. children. d. adults.
4. The mnemonic DOTS is used to assess: a. bleeding. b. other types of disabilities such as deformities. c. circulation and nerve damage before and after applying a splint. d. all of the above.
922
❖
CHAPTER 35
5. Defibrillation is performed on: a. adults. b. children. c. infants. d. a and b. 6. Which of the following would indicate the proper triage order for the conditions listed below? a. Sore throat, asthma attack, non-life-threatening bleeding emergency, emotional crisis b. Asthma attack, emotional crisis, nonlife-threatening bleeding emergency, sore throat c. Asthma attack, non-life-threatening bleeding emergency, emotional crisis, sore throat d. Emotional crisis, asthma attack, nonlife-threatening bleeding emergency, sore throat 7. Which of the following symptoms are not associated with diabetic coma? a. Rapid and pounding pulse b. Skin which is red, hot, and dry c. A fruity odor coming from the patient d. Drowsiness 8. Patients who come in with a possible fracture would be placed in which of the following rooms? a. Cardiac bay b. Procedure room c. Examination room d. Laboratory
Web Activities 1. A patient has just been diagnosed with a peanut allergy. The physician would like you to go online and find out where the patient can order EpiPens. Find two companies that sell EpiPens and list how much each one would cost. 2. Search the Internet to find two of the most common clot busters used to treat stroke victims, and list common side effects of each one. 3. Use the Internet to look up the National Poison Control number that will put you in touch with the local poison control center.
CONNECTION Using your StudyWARE CD-ROM: ❖ Complete the Hangman activity for this chapter. ❖ Complete the Quiz for this chapter in Test Mode.
THE DVD LINK On your StudyWARE CD-ROM, go to the DVD Challenge for this chapter. View the DVD clip and respond to the following questions: 1. What did the medical assistant do for the patient upon arrival to give the patient some relief? 2. We couldn’t see if the medical assistant actually wore sterile gloves when applying the sterile dressing. Should she have worn sterile gloves when applying the dressing? If so, why? Would her gloves have remained sterile when she picked up the saline bottle? 3. Why did the physician and medical assistant send the patient to the hospital and what did they do to provide the patient with some relief on the way to the hospital?
A PPE N DI X
A
Medical Abbreviations Common Charting Abbreviations ADL ADM AM amt ant AP ASAP ax BC BM BP BSE –c CC CMA (AAMA) c/o CPX Cx def DNS DOB DOI Dx EDC EDD EMS Ex FB FH FHS FTT HA H/O H&P HPI Hx lac LMP
activities of daily living admit; admission; admitted before noon amount anterior anterior/posterior as soon as possible axillary birth control bowel movement blood pressure breast self-examination with chief complaint certified medical assistant complains of complete physical exam canceled deficiency did not show date of birth date of injury diagnosis expected date of confinement expected date of delivery emergency medical services exam foreign body family history fetal heart sounds failure to thrive headache history of history and physical history of present illness history laceration last menstrual period
L Lt or 嘷 L&W NB N/C neg NKA NKDA N/V OV PA PH px PX or PE PM postop prog Pt RMA R/O ROM R Rt or 嘷 Rx –s SH spec SOAP
SOB S&S STAT surg Sx or sx UCHD VO –– w w/o WNL yr
left living and well newborn no complaints Negative No known allergies no known drug allergies nausea and vomiting office visit posterior/anterior past history prognosis physical exam afternoon post operative prognosis patient registered medical assistant rule out range of motion right prescription without social history specimen subjective, objective, assessment, plans shortness of breath signs and symptoms immediately surgical or surgery symptom usual childhood diseases verbal order with without within normal limits year
924
❖
APPENDIX A
Common Laboratory Abbreviations A1c or A1C ABG ACTH ADH ALB ALP bi or bx BS BT BUN C&S Ca CBC CEA Chem Chol CLCO CO2 CPK Creat CSF Diff EBV ELISA ETOH ESR FBS Fe FSH GC glob GTT hb or hgb HbA1c or HgA1c or A1c HCG Hct HDL HGH HIV
Hemoglobin A1c arterial blood gases adrenocorticotropic hormone antidiuretic hormone albumin alkaline phosphatase biopsy blood sugar bleeding time blood, urea, nitrogen culture & sensitivity calcium complete blood count carcinoembryonic antigen chemistry cholesterol chloride carbon monoxide carbon dioxide creatine phosphokinase creatinine cerebrospinal fluid differential Epstein Barr Virus enzyme-linked immunoasorbent assay ethyl alcohol erythrocyte sedimentation rate fasting blood sugar iron follicle stimulating hormone gonorrhea culture globulin glucose tolerance test hemoglobin hemoglobin A1c
human chorionic gonadotropin hormone hematocrit high density lipoprotein human growth hormone human immunodeficiency virus
H&H H Pylori INR K Lab LDH LDL LFT Mag Mono Na P Pap PAT Path PBI PKU POL PPE PSA PT PTT QA QC qns qs RBC or rbc RBS SG Staph STS Tb TC TG TP TSH T3 T4 UA UC VDRL WBC or wbc WNL
hematocrit and hemoglobin Helicobacter pylori bacterium international normalized ratio postassium laboratory lactic dehydrogenase low density lipoprotein liver function test magnesium mononucleosis sodium phosphorus Papanicolaou Test pre-admission testing pathology protein bound iodine phenylketonuria physician’s office laboratory personal protective equipment protein specific antigen pro-time partial thromboplastin time quality assurance quality control quantity non sufficient quantity sufficient red blood cell random blood sugar specific gravity staphylococcus serological test for syphilis tubercle bacillus throat culture triglyceride total protein thyroid stimulating hormone triiodothyronine thyroxine urinalysis; uric acid urine culture venereal disease reference lab white blood cell within normal limits
M E D I C A L A B B R E V I AT IO N S
❖
925
Common In-Office Procedure Abbreviations AP BP Drg or Drsg DVA ECG or EKG HC Ht NVA P
apical pulse blood pressure dressing distance visual acuity electrocardiogram head circumference height near visual acuity pulse
PFT R SaO2 T TPR VA VC VS Wt
pulmonary function testing respiration oxygen saturation rate temperature temperature, pulse, and respiration visual acuity vital capacity vital signs weight
NKDA noc NPO –p pc PDR ped PO or po PR PRN or prn q qid Rx –s sig sol STAT Subcut supp syr tab(s) tid tinc Ung W/O
no known drug allergies night nothing by mouth after after meals Physician’s Desk Reference powder by mouth per rectum as needed every four times a day prescription without let it be labeled solution immediately subcutaneous suppository syrup tablet(s) three times daily tincture ointment without
Common Medication Abbreviations –a ac Ad lib AM or am amp aq BC BID or bid –c Cap DAW dil DS D/W emul fl h or hr hypo ID IM Inj IT IV IVP IVPB Meds
before before meals as desired before noon or morning ampule water birth control twice a day with capsule dispense as written dilute double strength distilled water emulsion fluid hour hypodermic intradermal intramuscular injection inhalation therapy intravenous intravenous push intravenous piggyback medication
926
❖
APPENDIX A
Common Measurement Abbreviations g gt gtt kg IU lb
gram drop drops kilogram international units pounds
L mcg mEq mg ml or mL ng
liter microgram milliequivalent milligram milliliter nanogram
Common Symbols 䉭,d ↓ ' 䊊 or 乆 " ↑
嘷 L
change decrease foot female inch increase left
ⵦ or 么 ⫺ ⭋ # 䊊 ⫹
嘷 R
male negative none or negative number pint positive right
A PPE N DI X
B
ISMP’s List of Error-Prone Abbreviations, Symbols, and Dose Designations The abbreviations, symbols, and dose designations found in this table have been reported to ISMP through the USP-ISMP Medication Error Reporting Program as being frequently misinterpreted and involved in harmful medication errors. They should NEVER be used when communicating medical information. This includes internal communications, telephone/verbal prescription, computer-generated labels, labels for drug storage bins, medication administration records, as well as pharmacy and prescriber computer order entry screens.
The Joint Commission has established a National Patient Safety Goal that specifies that certain abbreviations must appear on an accredited organization’s donot-use list; we have highlighted these items with a double asterisk (**). However, we hope that you will consider others beyond the minimum the Joint Commission requirements. By using and promoting safe practices and by educating one another about hazards, we can better protect our patients.
ABBREVIATIONS
INTENDED MEANING
MISINTERPRETATION
CORRECTION
µg
Microgram
Mistaken as “mg”
Use “mcg”
AD, AS, AU
Right ear, left ear, each ear
Mistaken as OD, OS, OU (right eye, left eye, each eye)
Use “right ear,” “left ear,” or “each ear”
OD, OS, OU
Right eye, left eye, each eye
Mistaken as AD, AS, AU (right ear, left ear, each ear)
Use “right eye,” “left eye,” or “each eye”
BT
Bedtime
Mistaken as “BID” (twice daily)
Use “bedtime”
cc
Cubic centimeters
Mistaken as “u” (units)
Use “mL”
D/C
Discharge or discontinue
Premature discontinuation of medications if D/C (intended to mean “discharge”) has been misinterpreted as “discontinued” when followed by a list of discharge medications
Use “discharge” and “discontinue”
IJ
Injection
Mistaken as “IV” or “intrajugular”
Use “injection”
continued Courtesy of the Institute for Safe Medication Practices, www.ismp.org. Reprinted with permission.
928
❖
APPENDIX B
ABBREVIATIONS
INTENDED MEANING
MISINTERPRETATION
CORRECTION
IN
Intranasal
Mistaken as “IM” or “IV”
Use “intranasal” or “NAS”
HS
Half-strength
Mistaken as bedtime
hs
At bedtime, hours of sleep
Mistaken as half-strength
Use “half-strength” or “bedtime”
IU**
International unit
Mistaken as IV (intravenous) or 10 (ten)
Use “units”
o.d. or OD
Once daily
Mistaken as “right eye” (OD-oculus dexter), leading to oral liquid medications administered in the eye
Use “daily”
OJ
Orange juice
Mistaken as OD or OS (right or left eye); drugs meant to be diluted in orange juice may be given in the eye
Use “orange juice”
Per os
By mouth, orally
The “os” can he mistaken as “left eye” (OS-oculus sinister)
Use “PO,” “by mouth,” or “orally”
q.d. or QD**
Every day
Mistaken as q.i.d., especially if the period after the “q” or the tail of the “q” is misunderstood as an “i”
Use “daily”
qhs
At bedtime
Mistaken as “qhr” or every hour
Use “at bedtime”
qn
Nightly
Mistaken as “qh” (every hour)
Use “nightly”
q.o.d. or QOD**
Every other day
Mistaken as “q.d.” (daily) or “q.i.d. (four times daily) if the “o” is poorly written
Use “every other day”
q1d
Daily
Mistaken as q.i.d. (four times daily)
Use “daily”
q6PM, etc.
Every evening at 6 PM
Mistaken as every 6 hours
Use “6 PM nightly” or “6 PM daily”
SC, SQ, sub q
Subcutaneous
SC mistaken as SL (sublingual); SQ mistaken as “5 every;” the “q” in “sub q” has been mistaken as “every” (e.g., a heparin dose ordered “sub q 2 hours before surgery” misunderstood as every 2 hours before surgery)
Use “subcut” or “subcutaneously”
ss
Sliding scale (insulin) or ½ (apothecary)
Mistaken as “55”
Spell out “sliding scale;” use “one-half” or “½”
SSRI
Sliding scale regular insulin
Mistaken as selective-serotonin reuptake inhibitor
Spell out “sliding scale (insulin)”
SSI
Sliding scale insulin
Mistaken as Strong Solution of Iodine (Lugol’s)
1/d
One daily
Mistaken as “tid”
Use “1 daily”
TIW or tiw
3 times a week
Mistaken as “3 times a day” or “twice in a week”
Use “3 times weekly”
U or u**
Unit
Mistaken as the number 0 or 4, causing a 10fold overdose or greater (e.g., 4U seen as “40” or 4u seen as “44”); mistaken as “cc” so dose given in volume instead of units (e.g., 4u seen as 4cc)
Use “unit”
I S M P ’ S L I S T O F E R R O R - P R O N E A B B R E V I AT I O N S , S Y M B O L S , A N D D O S E D E S I G N AT I O N S
❖
929
DOSE DESIGNATIONS AND OTHER INFORMATION
INTENDED MEANING
MISINTERPRETATION
CORRECTION
Trailing zero after decimal point (e.g., 1.0 mg)**
1 mg
Mistaken as 10 mg if the decimal point is not seen
Do not use trailing zeros for doses expressed in whole numbers
No leading zero before a decimal dose (e.g., .5 mg)**
0.5 mg
Mistaken as 5 mg if the decimal point is not seen
Use zero before a decimal point when the dose is less than a whole unit
Drug name and dose run together (especially problematic for drug names that end in “L” such as lnderal40 mg; Tegretol300 mg)
Inderal 40 mg Tegretol 300 mg
Mistaken as Inderal 140 mg Mistaken as Tegretol 1300 mg
Place adequate space between the drug name, dose, and unit of measure
Numerical dose and unit of measure run together (e.g., 10mg, 100mL)
10 mg 100 mL
The “m” is sometimes mistaken as a zero or two zeros, risking a 10- to 100-fold overdose
Place adequate space between the dose and unit of measure
Abbreviations such as mg. or mL. with a period following the abbreviation
mg mL
The period is unnecessary and could be mistaken as the number 1 if written poorly
Use mg, mL, etc. without a terminal period
Large doses without properly placed commas (e.g., 100000 units; 1000000 units)
100,000 units 1,000,000 units
100000 has been mistaken as 10,000 or 1,000,000; 1000000 has been mistaken as 100,000
Use commas for dosing units at or above 1,000, or use words such as 100 “thousand” or 1 “million” to improve readability
DRUG NAME ABBREVIATIONS
INTENDED MEANING
MISINTERPRETATION
CORRECTION
ARA A
vidarabine
Mistaken as cytarabine (ARA C)
Use complete drug name
AZT
zidovudine (Retrovir)
Mistaken as azathioprine or aztreonam
Use complete drug name
CPZ
Compazine (prochlorperazine)
Mistaken as chlorpromazine
Use complete drug name
DPT
Demerol-PhenerganThorazine
Mistaken as diphtheriapertussis-tetanus (vaccine)
Use complete drug name
DTO
Diluted tincture of opium, or deodorized tincture of opium (Paregoric)
Mistaken as tincture of opium
Use complete drug name
HCl
hydrochloric acid or hydrochloride
Mistaken as potassium chloride (The “H” is misinterpreted as “K”)
Use complete drug name unless expressed as a salt of a drug
HCT
hydrocortisone
Mistaken as hydrochlorothiazide
Use complete drug name
HCTZ
hydrochlorothiazide
Mistaken as hydrocortisone (seen as HCT25O mg)
Use complete drug name
MgSO4**
magnesium sulfate
Mistaken as morphine sulfate
Use complete drug name
MS, MSO4**
morphine sulfate
Mistaken as magnesium sulfate
Use complete drug name
MTX
methotrexate
Mistaken as mitoxantrone
Use complete drug name
PCA
procainamide
Mistaken as Patient Controlled Analgesia
Use complete drug name
PTU
propylthiouracil
Mistaken as mercaptopurine
Use complete drug name
T3
Tylenol with codeine No. 3
Mistaken as liothyronine
Use complete drug name
TAC
triamcinolone
Mistaken as tetracaine, Adrenalin, cocaine
Use complete drug name
TNK
TNKase
Mistaken as “TPA”
Use complete drug name
ZnSO4
zinc sulfate
Mistaken as morphine sulfate
Use complete drug name
930
❖
APPENDIX B
STEMMED DRUG NAMES
INTENDED MEANING
MISINTERPRETATION
CORRECTION
“Nitro” drip
nitroglycerin infusion
Mistaken as sodium nitroprusside infusion
Use complete drug name
“Norflox”
norfloxacin
Mistaken as Norflex
Use complete drug name
“IV Vanc”
intravenous vancomycin
Mistaken as lnvanz
Use complete drug name
SYMBOLS
INTENDED MEANING
MISINTERPRETATION
CORRECTION
Dram
Symbol for dram mistaken as “3”
Use the metric system
Minim
Symbol for minim mistaken as “mL”
Use the metric system
x3d
For three days
Mistaken as “3 doses”
Use “for three days”
> and <
Greater than and less than
Mistaken as opposite of intended; mistakenly use incorrect symbol; “< 10” mistaken as “40”
Use “greater than” or “less than”
/ (slash mark)
Separates two doses or indicates “per”
Mistaken as the number 1 (e.g., “25 units/ 10 units” misread as “25 units and 110” units)
Use “per” rather than a slash mark to separate doses
@
At
Mistaken as “2”
Use “at”
&
And
Mistaken as “2”
Use “and”
+
Plus or and
Mistaken as “4”
Use “and”
°
Hour
Mistaken as a zero (e.g., q2° seen as q 20)
Use “hr,” “h,” or “hour”
**These abbreviations are included on the Joint Commission’s “minimum list” of dangerous abbreviations, acronyms, and symbols that must be included on an organization’s “Do Not Use” list, effective January 1, 2004. Visit http://www.jointcommission.org for more information about this Joint Commission requirement. Permission is granted to reproduce material for internal newsletters or communications with proper attribution. Other reproduction is prohibited without written permission. Unless noted, reports were received through the USP-ISMP Medication Errors Reporting Program (MERP). Report actual and potential medication errors to the MERP via the web at www.ismp.org or by calling 1-800-FAIL-SAF(E). ISMP guarantees confidentiality of information received and respects reporters’ wishes as to the level of detail included in publications.
A PPE N DI X
C
Commonly Misspelled Everyday Terms absence accidentally accommodate accumulate achievement acquaintance acquire advice advise affect analysis analyze annual appearance ascend balance belief believe beneficial benefited business calendar candidate capital capitol category changeable choose chose coarse conscience conscious coming commission complement
compliment course definition describe description desperate device devise disappearance disappoint disastrous discipline dissatisfied effect eighth eligible eliminate embarrass ensure environment equipped especially exaggerate excellence existence existent experience explanation familiar fascinate February foreign formerly forty fourth
generally grammar grievous height humorous immediately incidentally independence inevitable insure intelligence knowledge laboratory laid led maintenance maybe necessary ninety noticeable occasionally occurred occurrence omitted opinion opportunity optimistic paid particular performance permissible personal personnel perspiration physical
932
❖
APPENDIX C
possibility possible practically precede precedence preference preferred prejudice preparation prevalent principal principle privilege probably procedure proceed profession professor prominent pronunciation
pursue quantity quizzes recede receive receiving recommend reference referring repetition rhyme rhythm salary schedule seize sense separate separation severely similar
sincerely specifically stationary stationery statue studying succeed succession technique temperamental tendency tragedy transferring tries truly unnecessary until usually weird whether
A PPE N DI X
D
Commonly Misspelled Medical Terms abscess aneurysm anemia arrhythmia brachial calcaneus catheterization cirrhosis clavicle conscious curettage diaphragm elicit endometriosis epididymis hemorrhage hemorrhoids homeostasis
humerus ischium ilium ileum illicit inflammation ischemia larynx malaise melanoma mucous mucus ophthalmology palliative paralysis paralyze parenteral pharynx
phlegm pneumonia pruritis psychiatrist pyrexia rheumatic roentgenology sagittal specimen sphygmomanometer staphylococcus tetanus tonsil trachea unconscious vein vesicle
A PPE N DI X
E
Top 50 Drugs TRADE NAME
GENERIC NAME
CLASSIFICATION
SCHEDULE
Actonel
risedronate sodium
bone resorption inhibitor
nonscheduled
Actos
pioglitazone hydrochloride
oral antidiabetic agent
nonscheduled
Adderall XR
amphetamine
CNS stimulant
C-II
Advair Disks
fluticasone propionate
bronchodilator
nonscheduled
Altace
pioglitazone hydrochloride
oral antidiabetic agent
nonscheduled
Ambien
zolpidem tartrate
sedative; an agent to treat insomnia
C-IV
Avandia
rosiglitazone maleate
oral antidiabetic agent
nonscheduled
Celebrex
celecoxib
NSAID
nonscheduled
Chantix
varenicline
smoking deterrent
nonscheduled
Concerta
methylphenidate
CNS stimulant
C-II
Corez
carvedilol
antihypertensive cardiac glycoside
nonscheduled
Cozaar
losartan potassium
antihypertensive
nonscheduled
Crestor
rosuvastatin
cholesterol lowering agent
nonscheduled
Cymbalta
duloxetine
antidepressant
nonscheduled
Digitek
digoxin
cardiac glycoside
nonscheduled
Diovan
valsartan
antihypertensive
nonscheduled
Effexor XR
venlafaxine
antidepressant
nonscheduled
Flomax
tamsulosin HCl
drug used to treat BPH
nonscheduled
Fosamax
alendronate sodium
bone resorption inhibitor
nonscheduled
Klor-Con
potassium chloride
potassium supplement
nonscheduled
Lantus
insulin glargine [rDNA origin]
antidiabetic
nonscheduled
TOP 50 DRUGS
❖
935
TRADE NAME
GENERIC NAME
CLASSIFICATION
SCHEDULE
Levaquin
levofloxacin
antibiotic
nonscheduled
Levoxyl
levothyroxine sodium
hormone replacement (thyroid)
nonscheduled
Lexapro
escitalopram oxalate
antidepressant
nonscheduled
Lipitor
atorvastatin calcium
cholesterol lowering agent
nonscheduled
Lotrel
amlodipine besylate and benazepril HCl
antihypertensive
nonscheduled
Lyrica
pregabalin
anticonvulsant
nonscheduled
Nasonex
mometasone furoate monohydrate
anti-inflammatory corticosteroid
nonscheduled
Nexium
esomeprazole magnesium
antiulcer
nonscheduled
Norvasc
amlodipine besylate
antihypertensive; antianginal
nonscheduled
Plavix
clopidogrel
platelet inhibitor
nonscheduled
Premarin Tabs
conjugated estrogen
hormone replacement (estrogen)
nonscheduled
Prevacid
lansoprazole
antacid
nonscheduled
ProAir HFA
albuterol sulfate
bronchodilator
nonscheduled
Protonix
pantoprazole
antacid (proton pump inhibitor)
nonscheduled
Risperdal
risperidone
antipsychotic
nonscheduled
Seroquel
quetiapine fumarate
antipsychotic; antimanic agent
nonscheduled
Singulair
montelukast sodium
antiasthma (drug used to treat asthma)
nonscheduled
Synthroid
levothyroxine
hormone replacement (thyroid)
nonscheduled
Topamax
topiramate
anticonvulsant; antimigraine
nonscheduled
Toprol XL
metoprolol succinate
antihyptertensive
nonscheduled
Tricor
fenofibrate
cholesterol lowering agent
nonscheduled
Valtrex
valacyclovir
antiviral
nonscheduled
Viagra
sildenafil citrate
agent used to treat erectile dysfunction
nonscheduled
Vytorin
ezetimibe/simvastatin
cholesterol lowering agent
nonscheduled
Yasmin
drospirenone and ethinyl estradiol
contraceptive
nonscheduled
Zetia
ezetimibe
cholesterol lowering agent
nonscheduled
Zyrtec
cetirizine
antihistamine
nonscheduled
G l o s s a r y abortion: termination of pregnancy prior to the fetus becoming viable; may be induced or spontaneous, as in the case of a miscarriage abrasion: superficial scrape that may be very painful abscess: localized infection acclimate: to become accustomed to a new environment or situation Accrediting Bureau of Health Education Schools (ABHES): accrediting organization that oversees accreditation standards for various certifying bodies, such as the American Medical Technologists acquired immune deficiency syndrome (AIDS): disease caused by the human immunodeficiency virus (HIV), which destroys the immune system’s ability to fight infections active listening: listening to focus on the information at hand activities of daily living (ADLs): activities that are performed on a daily basis such as bathing, dressing, grooming, eating, and walking acute abdomen: sudden or abrupt onset of intense abdominal pain adaptive questioning: set of questions designed to draw the patient into the conversation and allow the patient to incorporate past experiences into the learning process ADA Standards for Accessible Design: federal standards that mandate construction companies to design buildings that are accessible to all persons, including those who have dexterity and limited mobility problems addendum: addition or supplement additive: substance such as a clot activator, separator gel, anticoagulant, or cell preservative that helps to maintain the integrity or function of the specimen administer: to prepare and personally give the patient a medication through any method at the point of care adolescent: age classification that is related to the onset of puberty and development of secondary sex characteristics aerobic: class of bacteria that require oxygen to grow afebrile: without fever affinity: measurement of how tightly a drug attaches or binds to a receptor agar: gelatin-like substance containing additives and nutrients that support the growth and multiplication of microorganisms
ageism: false belief or prejudice against the elderly agglutination: antigen-antibody reaction that involves clumping of cells due to the antibody attaching itself to the antigen agonist: drugs that bind to cell receptors and affect or enhance the cell’s natural response algorithm: decision tree or detailed sequence of actions to perform based on the patient’s responses aliquot: portion of the whole specimen used for testing Alzheimer’s disease: the most common form of dementia that occurs in older adults and affects areas of the brain that control thinking, communication, and behavior ambulation: the ability to walk or move about freely amenorrhea: absence of menstrual flow American Association of Medical Assistants (AAMA): professional organization that promotes and certifies medical assistants American Medical Technologists (AMT): nonprofit certification agency and professional membership association that certifies medical assistants and other health care professionals American Sign Language (ASL): distinct language for the deaf; considered the native language of the deaf Americans with Disabilities Act (ADA): act that requires businesses to extend civil rights to people with disabilities similar to those now available on the basis of race, color, sex, national origin, and religion; businesses may not discriminate against persons with disabilities and must provide an environment that accommodates the individual’s disability amniocentesis: procedure in which a needle is introduced into the amniotic sac through the mother’s abdominal wall to withdraw fluid for various lab tests amplifier: part of the the EKG unit that converts weak electrical signals coming from the heart into a more readable signal for the output device amplitude: when referring to an EKG, amplitude is the measure of the height of the cardiac deflection or the strength of the contraction ampule: glass container with a stem that holds a single dose of medication anaerobic: class of bacteria that do not require oxygen or that cannot grow when oxygen is present analyte: any substance that is being chemically analyzed
GLOSSARY
anaphylaxis: advanced systemic or allergic reaction to a chemical, drug, food, or insect sting or bite; symptoms may include bronchial constriction, swelling of the tongue or throat, and an inability to breathe anesthetic: medication used to produce a lack of feeling in patients undergoing a surgical procedure angiography: visualization of blood vessels after a radiopaque contrast medium has been injected to assess blood flow, blood clots, hemorrhaging and aneurysms anisocytosis: marked difference in the size of cells, especially red blood cells anorexia nervosa: eating disorder in which the individual limits food intake or does not eat at all to the point of starvation anoscope: type of speculum used to visualize the anus and lower portion of the rectum antagonist: drugs that prevent or block a cell response antecubital space: front of the arm (or inside) at the bend of the elbow; site commonly used for venipuncture antibody: protein particle produced by B-lymphocytes of the immune system; attaches to a specific antigen to neutralize or control it anticipation skills: the ability to know what a provider needs before being asked; type of critical thinking anticoagulant: substance that keeps blood from coagulating or clotting antigen: invading organism such as a bacterium or virus that stimulates antibody production within the body antiserum: serum that contains antibodies to a specific antigen, used to perform blood typing apothecary: term formerly used for a pharmacist or chemist apothecary system: the original or primary system used for calculating and measuring medication dosages appearance: the outward or visible portion of a person appointment grid: grid that lists specific symptoms under a list of appointment actions; wherever the patient’s symptoms fall on the grid is the time frame in which the screener offers the patient an appointment aqueous: water-based solution arrhythmia: an irregular heart rhythm arthritis: inflammation of a joint or multiple joints with pain, swelling, stiffness, or deformity arthroscopy: visualization of a joint and joint capsule through a lighted instrument artifact: unwanted interference on an EKG tracing asepsis: free of germs aseptic technique: effort employed to reduce the spread of microorganisms aspirate: pulling back on the plunger of a syringe to make certain that the needle is not in a blood vessel aspiration: removal of excess fluid from a body cavity or structure assay: to test or analyze a substance to detect the presence, absence, or quantity of one or more components
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937
assessment: evaluation of the patient through medical questioning, physical examination, diagnostic and other lab testing; when referring to the “SOAP” format, assessment is an interpretation of subjective and objective findings assistive device: device such as a cane, crutches, walker, or wheelchair that helps a patient to walk or move about freely asthma: chronic lung disease causing the bronchial tubes to constrict and block the flow of air to and from the lungs astigmatism: abnormal curvature of the cornea causing blurred vision asymptomatic: without symptoms atelectasis: collapse of the lung alveoli, rendering them ineffective atraumatic needle: needle that is packaged with suture material fused to an eyeless needle atrial fibrillation: type of cardiac arrhythmia indicated by extremely rapid and incomplete contractions of 400 to 500 BPM; P waves are small, irregular, and cannot be differentiated attitude: the way one feels about someone or something atypical: not normal; nonconforming audio learner: one who learns more by listening to information audiologist: health care professional trained to identify and treat hearing or balance problems audiometer: device used to measure hearing acuity at different sound frequencies augmented leads: EKG limb leads; AVR, AVL, and AVF; these leads produce very small impulses and must be amplified by the EKG unit auricle: external ear auscultation: the act of listening to body sounds with the aid of a stethoscope autoclave: instrument that sterilizes items by displacing air with steam within its chamber and exposing items to large amounts of heat over a specified time period automated external defibrillator: defibrillator that is completely automated and easy to use; designed to shock the heart into a normal rhythm during periods of ventricular fibrillation auxiliary services: aids that assist in the communication process for patients with special needs, especially those with hearing disabilities, such as qualified interpreters, telephone handset amplifiers, assistive listening devices, telephones compatible with hearing aids, closed caption decoders, open and closed captioning, telecommunications devices for deaf persons (TDD), and videotext displays AVPU scale: scale commonly used to determine responsiveness in a victim that collapses or is involved in an accident bacilli: rod-shaped bacteria; may contain spores
938
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GLOSSARY
bacteria: single-celled microorganisms lacking a nucleus that can cause infections bandage: wrapping material placed over a dressing or a closed wound baseline: the flat, horizontal line separating two EKG cycles, or the point on an EKG in which there is no electrical activity; also known as the isoelectric line baseline value: initial results established for the purpose of comparing future results basophil: type of white blood cell, known as a granulocyte, that contains dark, purplish-black granules in the cytoplasm benign prostatic hyperplasia: benign condition in which the prostrate is enlarged bilirubin: orange-yellow pigment found in bile that is formed when RBCs are broken down; found in urine of patients with certain liver diseases bioavailability: the extent to and the rate at which a drug enters the blood plasma and is made available at the site of action biohazard: any substance contaminated with blood or body fluids that could transmit disease biological indicator: indicator that is used to check that all parameters, including temperature, timing, sterilant, and humidity reach the unit’s requirements necessary to kill endospores bipolar leads: EKG limb leads I, II, and III; referred to as bipolar because they measure impulses from two limbs simultaneously bloodborne pathogen: disease-causing microbe found in blood and blood components blood urea nitrogen (BUN): kidney function indicator test that measures the amount of nitrogen in the blood body language: gestures, postures, and facial expressions by which a person manifests various physical, mental, or emotional states and communicates nonverbally with others body mass index (BMI): numerical correlation between a patient’s height and weight used to calculate the patient’s body fat percentage body substance isolation (BSI): safeguard within the standard precautions regulations that requires the use of PPE and protective handling of all substances contaminated with any body fluid except sweat, even when blood is not visible body surface area (BSA): most accurate method of calculating drug dosages for infants and children up to 12 years of age bolus: loading dose of medication that is introduced directly through the vein as opposed to through an access port or IV line box lock: hinged part of the instrument found on ring handled instruments that contain ratchets bradycardia: heart rate below 60 beats per minute
bradypnea: abnormally slow breathing Braxton-Hicks contractions: periodic and painless irregular uterine contractions; not true labor bronchoscopy: procedure that utilizes a lighted scope to view the lungs buccal: medication placed between the gums of the upper molars and the inside cheek for rapid absorption into the blood stream bucky: special film holder that contains a moveable grid that helps to reduce the scatter of secondary radiation during an x-ray bulimia nervosa: eating disorder in which the individual develops a pattern of consuming large amounts of food (binging) followed by eliminating the food from the body by vomiting, using laxatives, or diuretics (purging) business associate agreement: document signed by all business partners that defines how PHI is to be handled butterfly: small winged needle attached to tubing and an adapter to be used with a syringe or vacuum tube system for venipuncture caesarian section (C-section): delivery of a fetus through a surgical incision into the uterus calipers: instrument used for measuring different parts of the body; body fat calipers are devices that measure skin folds on different parts of the patient’s body callback: phone calls made during office hours such as ordering prescriptions, faxing reports, and returning telephone calls to patients cannula: flexible tube that is used to insert medication within a body cavity or blood vessel capillary puncture: skin puncture method used to obtain small amounts of blood for testing; usually performed on fingertips or great toe carcinogen: cancer-causing agent cardiac catheterization: procedure in which a catheter is passed through a major vessel in the arm or leg and through the coronary arteries of the heart and the heart’s chambers to check for coronary occlusion and other heart related disorders cardiologist: medical doctor who specializes in treating diseases and disorders of the heart and related structures cardiopulmonary resuscitation: technique that is used to restore the victim’s breathing and heart action when they fail cardiovascular surgeon: physician who specializes in performing surgical procedures on the heart and related structures cardioversion: to restore normal sinus rhythm through the use of medications or electrical current cartilage: connective tissue located between the articular surfaces of the bones, joints, and vertebrae, which acts as a shock absorber cartridge unit: disposable, prefilled cartridge of medication that slips into a nondisposable injection device
GLOSSARY
cast: (1) device made of plaster or fiberglass used to immobilize a fracture or dislocation; (2) structure sometimes found in the urine due to the accumulation of protein in the renal tubules cataract: thickening of the eye lens resulting in a cloudy or opaque covering over the lens, which is usually transparent catheterization: insertion of a sterile tube directly into the bladder through the urethra to obtain a sterile urine specimen cell-mediated immunity: type of immunity involving Tlymphocytes, which directly attack cancer cells, fungi, and viruses to make them powerless in the body Celsius (C): the official scientific measurement of temperature; also called the centigrade scale Centers for Disease Control and Prevention (CDC): division of the United States Public Health Department; responsible for the development of standard precautions and universal precautions centrifuge: instrument that spins test tubes containing specimens at high speeds to separate and concentrate the components cerebrovascular accident (CVA): blockage or bleeding within the blood vessels of the brain; also known as a stroke certification: fulfillment of the necessary requirements of a specific organization to perform specific tasks, usually acquired through an assessment tool such as a test Certification Commission for Healthcare Information Technology (CCHIT): commission appointed by the U.S. Department of Health and Human Services (HHS) to develop and evaluate the certification criteria and inspection process for EHRs; this commission certifies a vendor’s EMR software Certified Medical Assistant (AAMA) [CMA (AAMA)]: medical assistant who has passed the medical assisting exam through the American Association of Medical Assistants cerumen: ear wax chemical indicator strip: strip that is used in processing instruments that helps to confirm conditions were met to achieve sterilization chest circumference: measurement of the chest at the nipple level to screen for physiological abnormalities of the heart and lungs chest compression: maneuver in which the rescuer pushes up and down on the chest several times to circulate the blood around the body for a victim whose heart has stopped chief complaint: the symptoms for which the patient is being seen child: age classification that correlates with school attendance cholangiography: visualization of the bile ducts for detection of possible stones or lesions
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cholesterol: type of lipid found in the blood; it is made in the liver and is the major component of bile chronological order: arranged in order by date and time; reverse chronological order is the opposite of chronological order, in which items are arranged with the most recent item on top circumcision: procedure in which the prepuce or foreskin of the penis is cut away; usually performed on newborns Civil Rights Act: act designed to protect individuals from being discriminated against because of race, color, sex, national origin, or religion clean-catch midstream specimen: urine specimen collected in a sterile container after cleansing the urinary meatus using only the middle stream of the specimen clinical diagnosis: identification of a disease or condition from facts obtained through the medical history, physical exam, lab testing, and radiological testing Clinical Laboratory Improvement Amendment (CLIA ’88): legislation enacted to protect the public by regulating all laboratory tests performed on human specimens clinician: health practitioner such as a physician, physician assistant, or nurse practitioner; can also refer to an individual that works in a clinical setting closed wound: wound that does not break the skin, such as contusions, hematomas, strains, and sprains clostridium difficile: the microorganism (bacterium) responsible for the condition known as pseudomembranous colitis; uncontrollable diarrhea cocci: round or spherical shaped bacteria collimator: device attached to the x-ray tube that controls the size and shape of the x-ray beam colonoscopy: examination of the colon with a lighted scope colony: collection or growth of bacteria that appears as spots on a culture medium colposcopy: visualization of the cervix and vagina through a lighted scope Commission on Accreditation of Allied Health Education Programs (CAAHEP): commission that oversees accreditation standards for various certifying bodies, such as the AAMA compassion: to show concern or empathy for another individual competency: checklist that is used by an evaluator to determine one’s knowledge of a specific skill complete blood count (CBC): group of blood tests that includes hemoglobin, hematocrit, red and white blood cell counts, differential count, and red blood cell indices comprehensive medical history: history covering the patient’s personal, social, and family history from the time of birth until the time that the history is developed computed tomography (CT): radiographic procedure that produces cross-sectional images of the body concentric circle: technique that is used to apply antiseptic; the medical assistant paints the antiseptic directly over the site starting in the center and working to the outer periphery
940
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GLOSSARY
conceptually accurate signed English (CASE): type of sign language that uses ASL conceptual signs but in English word order concierge medicine: practices in which patients pay a fee for special services such as continuous access to medical records and the ability to e-mail practitioners in the practice concussion: injury in which the brain is jarred condenser: part of a microscope that regulates and directs the light from the source to the specimen conduction system: elaborate group of electrical cells that work with the heart’s muscle cells, causing the heart’s chambers to contract in a sequential fashion confidentiality: to keep secret or private constrict: narrowing of a blood vessel contrast medium: substance that is either injected or ingested prior to x-ray studies that enhances internal structures for better visibility conversion: to change from one unit to another crash cart: cart that stocks all of the medications and supplies used in an emergency credentialing: documentation which validates that an individual has been successful in attaining the educational components necessary to perform a specific job title critical lab value: lab value that requires the immediate attention of a qualified provider cryosurgery: procedure in which unwanted tissue such as skin lesions and warts are destroyed by freezing the tissue cryotherapy: therapeutic use of cold modalities to treat an injury or other physical condition cubic centimeter (cc): metric unit commonly used to measure medications cultural diversity: unique differences in various cultures culture: to grow and identify microorganisms in a laboratory from a patient sample culture and sensitivity (C & S) test: test involving bacteria grown on a plate to which antibiotic disks have been added, to determine which drugs the bacteria is sensitive or resistant to culture medium: material (liquid or solid) containing nutrients that help bacteria to grow cystoscopy: insertion of a lighted scope into the urethra, which is then directed into the bladder for visual inspection cytology: (1) branch of science dealing with the configuration, structure, and function of cells; (2) laboratory department that performs microscopic examinations of cells, such as pap tests debridement: to remove dead tissue defecate: the act of evacuating or emptying the bowels defibrillation: procedure in which drugs or electrical shock is used to restore normal contractions defibrillator: device that delivers electrical shocks to the heart to restore normal rhythm dementia: ongoing and irreversible decrease in mental functioning affecting memory, reasoning, and judgment
dependability: to be reliable, dependable, or trustworthy depolarization: in reference to the heart, a discharge of electricity that commences the heart to beat desktop organizer: items that help to keep a desktop organized, such as file holders, card holders, letter trays, pencil holders, etc. diabetes: chronic metabolic disorder caused by an inability of the cells of the pancreas to produce insulin (Type I) or an inability of the body to properly utilize the insulin that is produced (Type II) diabetic coma: life-threatening condition in which the patient’s blood sugar is dangerously high, causing the patient to go into a coma dialysis: procedure in which the patient’s blood is passed through a machine that filters out waste products and returns the blood back to the patient’s body diaphoresis: profuse sweating diaphragm: part of a microscope that opens and closes to control the amount of light directed on the specimen; resembles the iris of the eye; also referred to as iris diaphragm diastole: phase when the cardiac ventricles relax diastolic pressure: period of least pressure in the arterial vascular system; the bottom reading of a blood pressure differential count: count of 100 white blood cells on a stained blood smear for the purpose of determining the approximate percentage of each type of white blood cell; red blood cell morphology is also observed differential diagnosis: identification of a disease or condition by comparing similar symptoms and performing diagnostic and lab tests to identify the unknowns, leading to a final diagnosis digital rectal exam (DRE): procedure in which the provider inserts his or her gloved finger into the patient’s rectum to check the size of the prostate dilation: expansion of the cervix during labor to facilitate passage of the fetus diluent: solution used to reconstitute powder discretionary calories: category appearing on the food pyramid which refers to food items that have little nutritional value but add calories to the diet disinfection: process of using special liquids or pasteurization techniques on inanimate objects to destroy or inhibit the growth of microorganisms dislocation: temporary displacement of a bone from its usual position in the joint dispense: to personally hand the patient a medication to take later; in ambulatory care, drug samples and stock samples are commonly dispensed to patients dissect: to cut open or cut apart distilled water: water from which impurities have been removed, making it chemically pure diurnal rhythms: biological processes or activities, such as hormone secretion, sleeping, feeding, etc., that must be in sync with the day and night cycle “Do Not Use” abbreviations list: list of abbreviations published by the Joint Commission; includes medical
GLOSSARY
abbreviations that are commonly misinterpreted and may no longer be used when documenting orders within the patient’s medical record or when writing orders that are to be sent to other health care facilities DOTS: mnemonic commonly used to check for injuries once the heart and lung function have been stabilized; includes checking for deformities, open injuries, tenderness, or swelling dowager’s hump: curvature of the spine creating a hump at the back of the neck; caused by osteoporosis drawer organizer: tray with separate compartments used to organize drawer space dressing: piece of bandage material placed over an open wound drug: any substance that produces a change in the function of a living organism; often used in the diagnosis, treatment, or prevention of a disease drug ceiling: maximum dose at which the drug will provide its greatest effect drug dosage: strength of the drug or amount to be given drug interaction: occurs when one drug diminishes or increases the effects of another drug duration: period of time that the patient has experienced symptoms dysmenorrhea: difficult or painful menstruation dyspnea: difficult or labored breathing dysrhythmia: irregularities in heart rhythm echoing: communication skill that involves simple repetition of the material; promotes further interaction and clarification eclampsia: progressed form of preeclampsia that may also include seizures and coma ectopic: abnormal position; tubal pregnancy education: field of study that provides a learner with information that can be used in the industry effacement: thinning and shortening of the cervix to permit the fetus to pass through efficacy: effectiveness of a drug electrocardiogram (EKG or ECG): recording or tracing of the electrical activity of the heart electrocardiograph: instrument or machine used to record the EKG electrocoagulation: procedure in which an electrical instrument is used to clot small blood vessels to help control bleeding during minor office procedures electrode: sensors attached to the patient’s skin during electrocardiography; designed to detect the electrical activity coming form the heart electrodesiccation: procedure in which an electrode from an electrosurgical unit touches the skin to stimulate tissue destruction and is frequently performed to treat spider angiomas, warts, and polyps electrofulguration: procedure in which an electrode from an electrosurgical unit does not touch the skin directly but instead is held 1 to 2 mm away from the skin to produce a sparking sensation; used to remove polyps and cancer cells
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electrolyte: solution, gel, or cream that helps to conduct electrical current during an EKG electronic health record (EHR): often used interchangeably with electronic medical record; however, some health informatics specialists describe it as a generic term for all electronic patient care systems electronic medical record (EMR): the patient’s medical record in digital format with full interoperability within an enterprise (hospital, clinic, practice) electrosection: procedure in which an electrode from an electrosurgical unit is used to incise or cut tissue for removal of a specimen electrosurgical procedure: procedure performed to destroy benign and malignant lesions, to cut or excise tissue, and to control bleeding embolus: air bubble, foreign body, or detached blood clot that makes its way from one part of the body (usually the heart) to the vessels within the brain emergency health history: history taken at the time of an emergency based on the patient’s presenting illness or injuries emergency medical services (EMS): service providing pre-hospital care to patients that are acutely ill or that have life-threatening injuries or illnesses empathy: to identify with another’s feelings and respond with understanding endospore: inner layer of the wall of a spore found in particular types of bacteria engineering controls: devices used in the workplace to separate employees from materials that can be hazardous, such as blood and OPIM enteral: pertaining to the alimentary canal or intestines; enteral medications are medications that go through the digestive tract eosinophil: type of white blood cell, known as a granulocyte, that contains orange-red granules in the cytoplasm epidemiology: the study of infectious diseases and their origin, cause, and patterns of occurrence episodic medical history: history developed on a current complaint (chief complaint and the HPI together) erectile dysfunction (ED): the inability of a man to achieve and maintain an erection during sexual intercourse; also known as impotence erythrocyte: red blood cell; transports oxygen to the cells of the body and carbon dioxide to the lungs erythrocyte sedimentation rate (ESR): measurement of how far red cells fall in a given amount of blood in one hour evacuated tube: collection tube that contains a vacuum that facilitates the collection of blood during venipuncture examination: the process of inspecting the body and its systems to determine the presence or absence of disease exhalation: the exhaling of waste products; breathing out expiration: see exhalation expiration date: date that guarantees the effectiveness and safe use of the medication up to the date posted on the package or container
942
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GLOSSARY
exposure control: plan developed by the employer as part of infection control to protect at risk employees from exposure to blood and OPIM extracorporeal shock wave lithotripsy (ESWL): shock waves that break kidney stones down into small particles so that they can pass through the urinary tract with more ease extravasation: infiltration or leaking of fluid into the tissue around the vein exudate: fluid secreted by tissue that may include blood, pus, dead cells, and tissue fluid as a result of disease or injury Fahrenheit (F): the standard grade of measurement generally used for temperatures in the United States familial stature: height or body type that occurs within a family family medical history: detailed information about the present and past health of the patient’s family members fastidious: bacteria that has special growth requirements; difficult to grow or culture febrile: feverish fecal occult blood: hidden blood found in the stool fenestrated: to have one or more openings fever: abnormal elevation of the body temperature first-morning specimen: urine specimen collected during the first voiding of the day first responder: the first person to arrive at the scene of an accident that is trained to respond to the needs of the victims fissure: linear ulcer located on the edge of the anus flow sheet: log sheet found in the patient’s chart that assists the physician in monitoring repetitive information fluoroscopy: x-ray of moving body structures in real time, similar to a movie Foley catheter: type of urinary catheter that has a balloon that inflates to keep the catheter in place fomites: inanimate objects, such as equipment, contaminated with infectious material and capable of transmitting disease fracture: break in a bone frail senior: person who cannot complete three or more ADLs independently frostbite: local injury of the skin due to freezing or subfreezing conditions fungi: group of microorganisms that includes yeasts and molds galvanometer: device within the EKG unit that changes the voltage coming from the patient’s heart into a mechanical action that produces a tracing gastroenterologist: medical doctor that specializes in treating diseases and disorders of the digestive tract and accessory glands gastroenterology: branch of medicine that specializes in treating diseases and disorders of the digestive tract and accessory glands gauge: diameter of the lumen of a needle generic name: official name of a drug
genogram: medical family tree geriatric: pertaining to older adults or seniors geriatrician: medical specialist who treats diseases and disorders of aging or older adults gerontologist: health care provider who cares exclusively for aging or older adults gerontology: study of old age gestation: period of time from conception to birth gesture: sign, signal, or cue used to communicate in combination with or apart from words glaucoma: eye disease characterized by an increase in intraocular pressure resulting in possible blindness gram (g, gm): unit used when measuring anything that has mass or weight Gram negative: bacteria that stain pink/red during the Gram staining process Gram positive: bacteria that stain purple during the Gram staining process Gram stain: special testing method that differentiates bacteria based on their color reactions to various stains gravida: the number of pregnancies a woman has had, including the current pregnancy grid: structure located inside the bucky made up of alternating strips of radiolucent and radiopaque material guide dogs: specially trained dogs that guide their visually impaired or blind owners handle: the part of the instrument that the surgeon uses to hold the instrument head circumference: measurement that traces the growth of the cranium and the brain health information technology (HIT): technology or software developed for health care organizations Health Insurance Portability and Accountability Act of 1996 (HIPAA): another name for privacy act; act that governs and protects the handling of protected health information heat cramp: cramps caused by the body becoming overheated; the least serious of all of the heat emergencies heat exhaustion: condition in which a victim becomes overheated, causing the victim to sweat and lose large volumes of water and salts heat stroke: occurs when the body is either unable to cool itself down due to dehydration, physiological conditions, or a progression of heat exhaustion factors that go untreated; may lead to death if untreated hematocrit: percentage of packed red blood cells in a given volume of blood hematology: the study of blood and blood-forming tissues hematoma: swelling or accumulation of blood due to leakage from a blood vessel during or following venipuncture hematuria: presence of blood in the urine; intact red cells present in the urine upon microscopic examination hemoconcentration: pooling of blood at the venipuncture site caused by leaving the tourniquet in place too long; may lead to inaccurate test results hemodialysis: dialysis in which the patient is hooked up to a dialysis unit through tubes that connect to the patient’s blood vessels
GLOSSARY
hemoglobin: pigment in the red blood cells that carries iron and oxygen hemoglobinuria: blood found in the urine without the presence of intact red blood cells hemolysis: rupturing of the red blood cells during venipuncture, which releases hemoglobin into the serum or plasma, giving it a reddish appearance hemorrhaging: uncontrollable bleeding hemorrhoids: painful, swollen, and bleeding veins in the anal region hemostasis: stopping the flow of blood hepatologist: medical doctor that specializes in treating diseases and disorders of the liver hernia: protrusion of a body part through a surrounding area into a body cavity, creating a visible bulge high-density lipoprotein (HDL): lipoprotein that removes cholesterol from the body by taking it to the liver, where it is excreted in bile; “good cholesterol” high-level disinfectant: disinfectant that destroys all forms of microorganisms except high levels of bacterial spores; may be used on non- or semi-critical devices histology: (1) the study of tissues; (2) the laboratory department that prepares tissue samples for examination to determine the presence of disease history of the present illness (HPI): series of symptoms or signs that are related to the patient’s complaint Holter monitor: portable ambulatory EKG worn by the patient for 24 hours to detect cardiac arrhythmias homeostasis: state of equilibrium within the body when systems are functioning normally; state in which the body’s internal conditions are able to remain constant in the midst of changing environments hospice: program that provides palliative care to terminally ill patients human chorionic gonadotropin (hCG): hormone produced by the fertilized egg that is present in the blood and urine of pregnant females humoral immunity: type of immunity that involves antibody production by B cells hyperbaric oxygen (HBO2) therapy: therapy involving placing the patient into a hyperbaric chamber to treat difficult wounds; elevated level of oxygen under decreased pressure helps to increase oxygen stores in the blood stream and at the wound site, resulting in faster healing hyperglycemia: increased levels of glucose in the blood hyperopia: farsightedness hyperpnea: increase in respiratory rate or breathing that is rapid and deeper than normal hypertension: high blood pressure hyperthermia: state in which the body temperature is elevated above the normal range hyperventilation: rapid and deep respirations that result in higher blood oxygen levels and lowered carbon dioxide levels hypodermic: pertaining to under the skin; when referring to syringes, it is a syringe that punctures the skin hypoglycemia: decreased levels of glucose in the blood
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hypotension: low blood pressure hypothermia: condition in which the victim’s core body temperature falls below 95°F; may lead to death if left untreated hypoxic: decreased oxygen level immunity: the body’s ability to protect itself from diseases, pathogens, and their toxins immunizations: the process of stimulating an antibody reaction through the delivery of a vaccine in order to generate an immune response immunoglobulin: antibody produced by cells of the immune system that protects the body from pathogens immunology: laboratory department that performs testing to evaluate the body’s immune response and the levels of antibodies present in the blood immunosuppressed: patient whose immune system has been weakened by disease, chemotherapy, medications, etc., making the patient more susceptible to infection inanimate object: structures that are nonliving, including countertop surfaces, flooring, and examination tables incision: cuts in the skin usually made from items such as sharp instruments or glass incubation: the act of incubating; placing a culture in an environment that provides optimal temperature, humidity, and darkness for the purpose of growth and multiplication of microorganisms individually identifiable health information (IIPI): see protected health information (PHI) induration: degree of hardening of normally soft tissue infant: refers to the first year of life infection control: procedures used to decrease or prevent the spread of infectious microorganisms infectious waste: objects contaminated with blood, body fluids, or OPIM infiltration: see extravasation inflammatory response: the body’s attempt to protect itself from microorganisms that enter the body and to heal and replace injured tissue inhalation: the act of breathing in inhalers: handheld portable devices that deliver medication directly to the lungs initiative: to take the lead or to work independently inoculation: to apply microorganisms onto a culture medium inspection: visual examination of the surface of the body as well as the body’s posture and movement to detect disease and other conditions inspiration: see inhalation instillation: to instill liquid, such as medication, into a body orifice or cavity like the eye or ear Institute for Safe Medication Practices (ISMP): governmental organization specifically seeking ways to promote medication safety; the organization has compiled a “List of Error-Prone Abbreviations, Symbols, and Dose Designations,” which includes all of the “Do Not Use” abbreviations as well as several others that are often confused for other abbreviations
944
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GLOSSARY
instrumental activities of daily life (IADLs): activities such as making a doctor’s appointment, grocery shopping, taking medications, paying bills, and keeping the household functioning insulin shock: life-threatening condition in which the patient’s blood sugar drops to a dangerously low level, causing the patient to go into shock integrity: (1) to have character; (2) normal structure without damage, guaranteeing the purity of the specimen intermediate-level disinfectant: disinfectant that inactivates vegetative bacteria, mycobacterium, and most fungi, but does not necessarily kill spores interval health history: history built on a complaint from a previous visit; also referred to as a progress note intervals: in a lab setting, timelines in which particular lab tests should be performed; testing intervals may be based on age, health history, race, and a variety of other factors intra-articular: medication that is administered directly into a joint intradermal: within the skin intramuscular (IM): within the muscle intravenous pyelogram/pyelography (IVP): radiographic procedure that views the kidneys, uterus, and bladder after a contrast medium has been injected through an IV iris diaphragm: microscope structure that resembles the iris of the eye; can be opened or closed to increase or decrease the intensity of the light coming through the microscope; also referred to as a diaphragm irrigation: to flush a body canal, such as the eye or ear, with a flowing solution for the purposes of cleansing and removing debris and other unwanted objects ischemia: temporary lack of blood flow to an organ such as the heart isoelectric: the flat, horizontal line that separates the EKG cycles on the EKG tracing; another name for baseline Jaeger chart: assessment chart for near vision acuity consisting of a series of readings with the type ranging in size from newspaper headline print to the small print commonly found in telephone directories jaws: tips of certain instruments used to grasp or clamp items Joint Commission (JC): accrediting organization approved by the federal government which focuses on improving the quality and safety of care provided by health care organizations accredited by the commission ketone: normal products of fat metabolism found in the urine of patients with uncontrolled diabetes; can also be found due to starvation and vomiting Korotkoff sounds: sounds heard during auscultation of the blood pressure laceration: jagged wound or cut that may be the result of a traumatic injury; may also appear as a tear lancet: sterile, disposable, sharp-pointed blade used to puncture the skin for the purpose of collecting a blood sample
language development: stage of development that begins with noises and progress into words, phrases, and sentences laser: instrument that uses a focused beam of light to remove unwanted tissue and control bleeding in a variety of invasive and noninvasive procedures leads: (1) a recording of the electrical impulses coming from the heart at different angles; (2) sensors or electrode conductors attached to the patient’s skin during an EKG leukocyte: white blood cell; main function is to fight infection and tissue damage licensing: legal document that permits or authorizes a person to perform a specific task or tasks. Examples of professionals who must be licensed to practice medicine include doctors, dentists, and nurse practitioners; currently, no state offers licensing opportunities for medical assistants ligature: (1) the act of tying or binding; (2) suture material used to tie off tubular structures such as the fallopian tubes or vas deferens following a surgical procedure limited English proficiency (LEP): persons with a primary language other than English or those who have a difficult time, reading, speaking, or comprehending English lipemia: abnormal amount of fat in the blood causing the serum or plasma to appear cloudy or milky lipoprotein: simple protein bound to fat (cholesterol) that carries lipids in the blood liter (L): fundamental unit of volume when measuring liquids local reaction: allergic reaction to a drug that involves only the local tissue such as hives, swelling, and tenderness lochia: discharge of blood, mucous, and tissue from the uterus following delivery lot control: identifying number that allows the medication to be tracked in the event of a recall low-density lipoprotein (LDL): lipoprotein deposited as fat in the tissues of the body and in the walls of the blood vessels, which increases the risk of coronary artery disease; “bad cholesterol” low-level disinfectant: disinfectant that kills most types of bacteria and some viruses; may only be used on noncritical devices Luer-Lok: special tip on a syringe that allows the needle to be screwed onto the syringe for a snug fit lymphocyte: type of white blood cell with no granules in the cytoplasm; responsible for a major portion of the body’s immune response macrocephaly: abnormally large head that may indicate a pathologic disorder macrocyte: larger than normal red blood cell magnetic resonance imaging (MRI): diagnostic imaging procedure that uses a magnetic field to produce images of the body manipulation: applying passive movement to a joint while using force
GLOSSARY
Mantoux skin test: common screening test for tuberculosis massage: the use of pressure, friction, and kneading to promote muscle relaxation meconium: earliest stools of the newborn medical asepsis: cleansing methods used to destroy microorganisms found in blood and other body fluids once they leave the body medication label: product label that gives vital information about the medication medicinal: relating to or having the properties of a medication menarche: woman’s first menstrual cycle menopause: permanent cessation of menstruation menses: bloody discharge of the endometrial lining; occurs monthly during a woman’s fertile years if fertilization is not achieved menstruation: see menses mensuration: the act of measuring, including height and weight measurements mental health: person’s state of mind; how people look at themselves, their lives, and the other people in their lives, evaluate their challenges and problems, and explore choices mental illness: condition or illness that impairs the mind’s ability to process information in a “normal” fashion mental impairment: see mental illness mentally challenged: individual whose brain functions at a subnormal intellectual level metabolism: sum of all chemical and physical changes that take place within an organism meter (m): fundamental unit of length when measuring distance metered-dose inhalers (MDI): inhalers that use a chemical propellant to push the medication out of the inhaler and deliver it to the patient’s lungs by direct inhalation or by squeezing the canister metric system: primary system for measuring weight, volume, and length (area) metrorrhagia: periods of bleeding between the regular monthly flow microbiology: (1) the study of microorganisms, especially as they relate to infectious diseases; (2) the laboratory department that grows and identifies microorganisms microcephaly: abnormally small head that may indicate a chromosomal disorder microcyte: smaller than normal red blood cell microorganism: microscopic living organism such as bacteria, viruses, fungi, and protozoa milestones: set of activities which indicate acceptable growth and development patterns minerals: inorganic elements that are essential for normal body function and include elements such as sodium, potassium and magnesium miscarriage: loss of a fetus before viability; also known as spontaneous abortion
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945
modality: physical agent such as, heat, cold, water, and electricity used in physical therapy to improve or restore lost function to musculoskeletal tissue monocyte: type of white blood cell with no granules in the cytoplasm containing a large, irregularly shaped nucleus morphology: study of structure and form; when referring to red blood cell morphology, it is a study of the cells’ size, shape, and the amount or lack of color motor development: area of development that includes reflexes, gross motor, and fine motor skills mounting: the process of placing a portion of each lead tracing in a mounting folder or on an adhesive mounting card for easy viewing multidrug-resistant TB (MDR-TB): strain of TB resistant to two or more drugs that are typically used to treat tuberculosis myocardial infarction: heart attack myopia: nearsightedness National Drug Code (NDC): numbers used to identify the manufacturer, the product, and the size of the container nebulizer: instrument used for the treatment of asthma and other lung conditions that changes liquid medications into an aerosol mist so that they can be inhaled through a mouthpiece or facemask neonate: refers to the first month of life nephrologist: kidney specialist neurologist: physician who specializes in diagnosing and treating diseases and disorders of the nervous system, including the brain, spinal cord, and nerves neutrophil: most common type of granulocytic white blood cell that contains light purple granules in the cytoplasm newborn: refers to the initial period following birth nomogram: graph that illustrates a relationship between two known values normal flora: microorganisms normally present in different parts of the body that are non-pathogenic and pose no health threat to the host under ordinary circumstances; may provide protection to the host normal sinus rhythm: the heart’s rhythm within normal limits normal value: values or ranges that are expected in certain populations; each lab has its own set of normal values based on test methodology and the testing population normocyte: normal sized cell notice of privacy practices: notice given to and signed by patients explaining how their PHI will be used nuclear medicine: branch of medicine that uses radioactive isotopes for the purpose of diagnosing and treating diseases obesity: condition present when a person is 20% to 30% over the normal weight for their age, size, and gender objective: part of a microscope that contains a magnifying lens for viewing specimens objective impressions: information provided by the clinician or provider that includes a list of measurable or reproducible data
946
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GLOSSARY
observation: the process of watching or visualizing occlusion: lockage or closure that may occur during IV therapy, which blocks the medication from going into the vein occult: medical term for “hidden” Occupational Safety and Health Administration (OSHA): government agency that sets forth regulations for a safe and healthy workplace occupational therapist (OT): medical professional who is responsible for assisting patients with basic motor function, reasoning, and activities of daily living ocular: eyepiece of the microscope opened-container life: amount of time a disinfecting solution may be used once the bottle has been opened open wound: wound that breaks the skin, including abrasions, incisions, lacerations, and punctures ophthalmic: pertaining to the eye ophthalmologist: medical doctor who specializes in the diagnosis and treatment (including surgery) of diseases and disorders of the eye ophthalmoscope: instrument used to visualize the interior of the eye opportunistic infections: infections that normally do not occur unless the infected individual has an impaired or weakened immune system optician: eye professional (technician) who fills prescriptions for eye glasses optometrist: doctor of optometry licensed to perform visual acuity testing and able to prescribe corrective lenses to patients with refractive errors orthopedist: physician who specializes in the treatment of diseases and disorders of the bones and muscles orthopnea: breathing that is easiest while in a sitting or standing position orthostatic hypertension: blood pressure that drops upon standing osteoporosis: condition in which the bones become brittle and porous due to a lack of calcium storage in the bone other potentially infectious material (OPIM): body fluids other than blood that could be infectious otic: pertaining to the ear otorhinolaryngologist: the medical name for an ear, nose and throat doctor, or ENT otoscope: instrument used to visualize the external ear canal and tympanic membrane out guide: temporary file that replaces a chart that has been removed from the files ova and parasite (O&P): testing that is performed to identify intestinal parasites and their eggs or cysts in patients with symptoms of gastrointestinal infection oxygen saturation: the amount of oxygen in the hemoglobin of red blood cells (RBC) palliative care: care often extended to terminally ill patients that simply relieves pain and keeps the patient comfortable palpate: method of examination that uses touch to locate veins for venipuncture
palpation: examination by application of the hands and fingers to the body to evaluate size and function of the body and to determine abnormality in size or texture panic lab value: lab value that requires the immediate attention of a qualified practitioner; may or may not be considered life threatening, but usually is quite serious para: number of live births parasite: organism that lives within, upon, or at the expense of the host parenteral: pertaining to outside of the intestines; any drugs delivered by a method other than through the digestive tract paresthesia: tingling or burning sensation associated with nerve injury or damage parietal pain: pain in the abdominal wall caused by inflammation and aggravated by movement Parkinson’s disease: chronic neurological disease that inhibits the production of dopamine, important in coordinating movement paroxysmal atrial tachycardia (PAT): sudden onslaught of increased heart rate ranging from 150 to 250 BPM participating provider: clinician or facility that contracts with an insurance company to provide laboratory or diagnostic services parturition: another term for labor passive euthanasia: allowing a patient to die with dignity and withholding procedures or drugs that would prolong life past history (PH) or past health history (PHH): record of usual childhood diseases and other diseases, conditions, injuries, and hospitalizations that the patient has endured in the past patency: the openness of a structure in the case of an IV; usually referring to veins pathogen: disease-causing microorganism pathogenic: disease producing peak expiratory flow (PEF): test that measures the speed of exhalation with the greatest effort peak flow meter: small handheld device that measures peak expiratory flow; used to monitor lung ailments such as asthma pediatric: specialty with a focus on working with patients from birth through young adulthood pediatrician: medical specialist who treats the patient population from birth through young adulthood (usually age 18) pending: something that is to occur; a pending file in a medical office is a patient’s file awaiting a task to be performed percentiles: group of percentages that compare measurements such as height and weight to other children of the same age percussion: to use the fingertips to tap the body slightly but sharply to determine position, size, and consistency of an underlying structure or cavity
GLOSSARY
perimenopause: phase 1 of menopause; the beginning of menopause, characterized by irregular menses and amenorrhea peritoneal dialysis: dialysis in which a tube is placed into the patient’s abdomen to filter blood in patients who are in kidney failure personal health record (PHR): copy of the patient’s own medical record that may be in paper or digital format personal medical history: history of the patient’s current and previous health concerns personal protective equipment (PPE): items that place a barrier between the employee and blood or OPIM, such as gloves, goggles, and gowns pH: measure of the acidity or alkalinity of a substance pharmacodynamics: the study of the effects of drugs on living organisms pharmacokinetics: describes how the body reacts to a drug pharmacology: the study of drugs, including their origin, nature, properties, and effects upon living organisms phenylketonuria (PKU): congenital and familial disease in which the patient is deficient in the enzyme phenylalanine hydroxylase, which prevents the patient from converting phenylalanine to a protein needed for metabolism phlebitis: inflammation of the vein phlebotomist: health care employee who performs phlebotomy or blood drawing procedures phlebotomy: act of drawing blood physiatrist: physical medicine doctor who diagnoses and treats neuromuscular and bone diseases and injuries; works closely with the physical therapist physical disability: impairment restricting or preventing normal functioning of a particular limb or group of limbs physical therapist (PT): medical professional who is responsible for the management of a patient’s rehabilitation through the use of different physical means or modalities physical therapy: therapy that develops, maintains, and restores maximum movement to muscloskeletal tissue physician’s office laboratory (POL): laboratory located in physicians’ offices to provide clinicians with faster turnaround times in relation to test results; tests may be waived or moderately complex plan: part of the SOAP note that includes plans for testing, treatment, and education for each problem for which the patient is seen plasma: liquid portion of whole blood; obtained when the blood is centrifuged in a blood drawing tube containing an anticoagulant and separated from the cells pleural effusion: excessive amount of fluid in the pleural space poikilocytosis: marked difference in the shape of the red blood cells point-of-care testing (POCT): testing performed at the point of care (the patient’s bedside, in the exam room, etc.)
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947
postlingual: individuals who became deaf after they started speaking postpartum: time period between the delivery of the baby to the time of the mother’s six week check-up following delivery posture: the position of the body whether standing, sitting, or lying down precertification: process by which certain procedures must be approved prior to being performed in order to be covered by an insurance company precipitate: pieces of solid materials or crystals that may form from a chemical reaction in a medication vial precordial leads: the six chest leads of a standard 12-lead EKG preeclampsia: complication of pregnancy marked by an increase in blood pressure, protein in the urine, and edema; may progress rapidly to eclampsia; another name for toxemia prelingual: individuals who were deaf before they started speaking premature atrial contraction (PAC): premature contraction of the atria of the heart; arrhythmia that starts in the atria premature ventricular contractions (PVCs): premature contraction of the ventricles; arrhythmia that starts in the ventricles prenatal: before birth presbyopia: farsightedness due to aging and the loss of elasticity of the lens prescribe: to order a medication from the pharmacy, usually by prescription prescription: order for a prescribed drug or treatment preventative health screening: screening that helps to identify health concerns before they develop into a problem primary container: original container in which the specimen was collected primary dressing: dressing that lies directly over the wound primary drug: drug that should be drawn first when combining two drugs in the same syringe problem list: list of specific problems identified by the patient history that is placed at the front of the patient chart for easy referencing problem-oriented medical record (POMR): medical record documentation format developed by Lawrence L. Weed in the early 1970s that incorporates organized structure within the medical chart proctologist: medical doctor who specializes in treating diseases and disorders of the lower bowel, rectum, and anus proctoscope: instrument used to visually inspect the anus and rectum procurement station: satellite locations where samples are collected product name: trade name or brand name of the medication
948
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GLOSSARY
professionalism: conduct, aims, or qualities that characterize or mark a professional or a professional person profile: related lab tests grouped by body system or function progress note: note that tracks a patient’s progress; the heart of the patient record; includes physician notes about current problems and is a chronological listing of the patient’s overall health status prophylactic: substances used to prevent or lessen the severity of a disease prosthesis: artificial joint or body part; device that augments natural function, like a hearing aid or an artificial limb protected health information (PHI): the patient’s private health information protocol: set of instituted guidelines based on office policy provider: health practitioner such as a physician, physician assistant, nurse practitioner, or other professional who works in a clinical setting provider-performed microscopy procedures (PPMP): microscopic examinations that are part of CLIA’s moderately complex category of tests; these examinations require the expertise of a physician or secondlevel provider qualified in microscopic procedures proxemics: the amount of surrounding space in which a person feels comfortable when standing or sitting next to another person puberty: age at which both males and females are able to reproduce puerperium: another name for the postpartum period pulmonary function testing: noninvasive test that detects the lung’s ability to function pulmonologist: physician who specializes in respiratory care pulmonology: medical specialty that involves caring for patients with specific respiratory disorders pulse oximeter: device to measure the oxygen saturation level of the blood pulse oximetry: indirect test used to measure pulse rate and oxygen levels in the blood pulse pressure: the difference between systolic and diastolic pressures pulse rate: the number of pulse beats per minute that can be counted and are assessed for regularity pulse rhythm: regularity of the pulse beats pulse volume: strength of the pressure felt when palpating a pulse for characteristics, such as strong or weak, bounding or thready puncture: wound that is usually caused by an object such as sticks, pins, nails, or pieces of glass that penetrate the skin, leaving a hole pure culture: culture that contains only one organism purified protein derivative (PPD): TB antigens used in the Mantoux screening test for tuberculosis purulent: discharge containing pus
quality assurance (QA): inclusive term for all policies, procedures, and practices that ensure reliable and accurate documentation, calibration, and maintenance of equipment, quality control, proficiency testing, and staff training quality control (QC): procedures that monitor the processing of laboratory specimens; includes test control samples, documentation, and analyzing statistics for diagnostic tests QuantiFERON-TB Gold Test (QFT-G): blood test that screens for tuberculosis quantity not sufficient (QNS): describes a specimen received by the lab whose volume is not sufficient to perform the required test query: to make a request for information; to mark an item with a notation in order to question its validity rad: radiation absorbed dose; the unit used to measure the amount of what is known as “ionizing” radiation that is absorbed during an x-ray procedure radiate: to send out or to spread to another location radiograph: see x-ray radiologist: medical specialist who uses radioactive substances for visualization of internal body structures and diagnosis and treatment radiolucent: penetrable by x-rays radionuclide: radioactive substance, such as iodine or cobalt, that is administered to patients prior to a nuclear medicine study radiopaque: unable to be penetrated by the x-ray beam; allows visiualization of tissue random collection: urine specimen collected at any time with no special preparation range of motion (ROM): exercise designed to move a joint through its full range of motion ratchet: the part of a ring handled instrument centered between the two rings; the locking mechanism that tightens or locks the tips of the instrument at varying degrees reagent test strip: narrow plastic strip with reagent pads that have been treated with specific chemicals to test urine for the presence of substances such as glucose, blood, bacteria, WBCs, bilirubin, urobilinogen, protein, and ketones reassurance: to calm the patient who is anxious receptor: bonding proteins or sites on cells to which drugs attach to stimulate or block a cell response recovery position: the patient is placed on their side to avoid choking and to keep the airway open during a lifethreatening emergency reduction: realignment of a bone back into to its original position following a break reference laboratory: large, independently owned, usually regionally located laboratories that perform complex or specialty tests
GLOSSARY
reference value: normal values or ranges for laboratory test results derived from the values obtained from 95% of a normal healthy population; varies according to test methodology of the laboratory referral: process in which one provider recommends the services of another provider, usually a specialist, to oversee certain aspects of the patient’s care referred pain: pain felt at a site away from the actual pain site; pain may radiate or travel reflexes: involuntary or automatic response to a stimulus refractive disorder: conditions in which the lens and cornea do not bend light correctly, resulting in visual defects refractometer: handheld device that consists of a lens and a prism; used in POLs to measure the specific gravity of urine Registered Medical Assistant (RMA): the medical assisting credential offered by the American Medical Technologists registration: to enroll a person’s name in a register, based on their successful completion of a specific program and/ or their ability to pass an examination designed specifically for that particular specialty regulated waste: any waste matter contaminated with infectious material that could pose a health threat due to transmission of pathogens rehabilitation: in regards to musculoskeletal rehabilitation, the act of restoring function and mobility to injured or diseased musculoskeletal tissue renal threshold: point at which a substance reaches a blood concentration high enough for the kidneys to start removing it and it is detected in the urine repolarization: period of relaxation of the heart requisition: laboratory request form that accompanies each specimen to the lab that contains all patient and physician information and identifies the tests to be performed resident flora: harmless flora normally present on the epidermis and dermis layers of the skin resistance: the ability to oppose a disease or toxin respiration: the act of breathing; one complete inhalation and exhalation retinopathy: any disorder of the retina reuse life: amount of time a solution may be used once it has been prepared or activated rhythm strip: separate 12-inch recording of a particular lead (generally lead II) to observe heart rhythm variances sanguineous: discharge or exudate that contains blood sanitization: cleaning process to remove tissue, blood, or body fluids from instruments or fomites, usually by scrubbing the items with a special soap sebaceous cyst: cyst that occurs as the result of a blocked sebaceous gland secondary dressing: dressing that is placed over a primary dressing and assists with absorption of excess wound fluid or exudates from the inside, while keeping outside moisture from entering the wound
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949
secondary drug: drug that should be drawn second when combining two drugs in the same syringe secondary sex characteristics: visual changes seen in males and females as they reach puberty sediment: solid material found in urine after centrifugation that is examined microscopically seizure: sudden attack that is usually the result of a malfunction in the brain senior abuse: mental or physical abuse to an aging adult who is unable to defend him or herself sensitivity testing: technique that evaluates which antibiotics will destroy a particular microorganism sensory development: development of the senses, such as vision and hearing, which continue to promote further motor development seroconversion: the point that detectable antibodies are present in the serum, causing a positive antibody test serosanguineous: discharge or exudate that contains both serum and blood serous: discharge or exudate that contains serum serrations: markings etched into the tips of certain surgical instruments to help improve gripping power when working with tissue that is slippery serum: liquid portion of the blood that remains after the blood has clotted; obtained from a blood drawing tube that does not contain an anticoagulant service: to extend help to others sexually transmitted disease (STD): also referred to as sexually transmitted infections; infections that are transmitted through sexual contact; examples include chlamydia, gonorrhea, and syphilis shank: connects the handle to the working end of the instrument and extends the instrument to work in deeper tissue sharps: sharp objects that could cause puncture wounds when handled, including needles, sharp instruments, scalpels, glass slides, glass tubes, and pipettes; these items should be placed in a sharps container to avoid injury shelf life: amount of time a solution may be stored unopened before losing its potency shingling: filing system commonly used for lab reports that are not on standard-size paper; reports are shingled in reverse chronological order about a half inch above each other shock: potentially fatal condition that can be brought on by disease, injury, decrease in circulation, and fluid loss; during shock, the blood may pool, preventing vital organs from receiving blood side effect: secondary effect in addition to the therapeutic effect; some side effects are therapeutic and end up becoming another use for the drug; however, most side effects are unpleasant and may even be harmful sighted guide assistance: to act as a guide for a person who is blind sigmoidoscopy: examination of the sigmoid colon with a lighted scope
950
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GLOSSARY
signed English: type of sign language similar to Signed Exact English (SEE), though it often borrows vocabulary terms from American Sign Language (ASL); more similar to ASL than SEE signed exact English (SEE): form of sign language that codes English words into a visual form sleep apnea: periods of breathing cessation during hours of sleep Snellen chart: chart used to test distance visual acuity social history: lifestyle questions such as amount of alcohol consumed in a regular week, number of packs of cigarettes smoked per day, etc. source-oriented medical record (SOMR): more traditional format used for entering data in the medical record; data is usually entered in narrative format in a related section of the chart; there is no systematic crossreferencing for this documentation format specific gravity: measure of the amount of dissolved substances found in the urine; measure of the concentration of the urine sphygmomanometer: instrument used to determine arterial blood pressure spirometer: device that is used during spirometry testing to measure breathing capacity spirometry: see pulmonary function testing splint: stiff device used to support and immobilize a part of the body that has been injured or fractured sprain: trauma to ligaments, tendons, or muscles sputum: fluid that is produced in the lungs and bronchi standardization: mark that is made at the beginning of each lead or group of leads when performing an EKG to make certain the unit is functioning properly Standard Precautions: set of precautions developed by the CDC that take universal precautions to the next level by treating all body fluids except sweat as though they are potentially infectious standing order: list of written orders developed by the physician for procedures that are to be performed when the patient complains of specific symptoms sterilant: high-level chemical disinfectant that has been cleared by the FDA as being capable of destroying all microorganisms, including large amounts of bacterial spores sterile conscience: continual mindset of sterility; making certain that nothing happens that compromises the patient’s safety before, during, or following the surgical procedure sterilization: the complete destruction of all microorganisms stool culture: test that looks in the stool for pathogenic bacteria or other microorganisms that cause intestinal symptoms. strain: injury to a body part caused by overuse or exertion stylus: heated wire on the EKG machine that produces the graphic tracing on the EKG paper
subatmospheric pressure device: device that uses negative pressure to help close wounds subcutaneous: under the dermis or true layer of skin subjective impressions: information provided by the patient subjective information: information supplied by the patient subjective, objective, assessment, plan (SOAP): charting format used in the POMR; each letter represents a different section of the documentation sublingual: medication placed under the tongue for rapid absorption of the medication into the blood stream sudden infant death syndrome (SIDS): death of an infant usually under one year of age with no known cause summarization: to restate material that has been presented and learned supernatant: liquid portion of urine that is discarded after centrifugation surgical adhesive: surgical glue containing sealants to hold a wound closed; used in place of staples or sutures surgical asepsis: procedures and practices used to destroy and eliminate all microorganisms from instruments and other objects in order to protect patients having surgical procedures from developing infections; maintaining sterile conditions during any invasive procedure surgical wick: device that is used to introduce medications into a body cavity such as the ear and eye or to act as a drainage conduit for wound management suture: (1) the process of sewing; (2) the type of strand or fiber used to sew; purpose of a suture is to hold the edges of a wound together until the natural healing process joins the tissue permanently symptom: signal or sign experienced by the patient indicative of a specific disease or condition; may include, pain, fever, itching, etc. syncope: brief episode of unconsciousness or fainting systemic reaction: reaction that affects the entire body systole: period in which the cardiac ventricles contract systolic pressure: the highest amount of pressure within the arteries during ventricular contraction tachycardia: heart rate greater than 100 beats per minute tachypnea: rapid respirations in combination with normal or shallow breathing; respiration rate is usually above 40 breaths per minute tact: acute sensitivity for knowing what to say and when to say it tactile learner: one who learns most by touching, holding, or by doing task box: electronic messaging system within the EMR that alerts users of tasks that need to be performed; may also be referred to as an electronic task manager task list: list of jobs that need to be completed within a certain time frame taut: to pull or draw tight, as when you pull the skin tight when administering an intramuscular injection
GLOSSARY
taxonomy: classification of living organisms into the proper category telecommunications: form of communication that allows participants to communicate at a distance; works by sending electromagnetic signals between such devices as the telephone, television, radio, and computer modem telecommunications device for the deaf (TDD): device that allows deaf persons to type messages over phone lines Telecommunications Relay Services (TRS): service for deaf persons when they are calling a party or business that does not have a TDD or TTY in which a relay operator relays information between the two parties telephone screener: specially trained individual that uses a telephone screening manual to screen patients calling about symptoms over the phone; usually does not involve as much professional judgment as the act of triaging telephone triage: form of triaging over the phone teletypewriter (TTY): type of TDD; typewriter that transmits messages between a deaf person and a hearing person via telephone lines testicular self-examination (TSE): procedure in which the patient examines his testicles monthly for any changes such as lumps or enlargement thanatology: research that studies death therapeutic communication: exchange of information between the health care worker and the patient that leads to the advancement of the patient’s physical and emotional well-being therapeutic effect: desired effect that a drug has on the body therapeutic index: range between the therapeutic dose of a drug and the dose at which the drug becomes toxic thermotherapy: applying dry or moist heat to a body part to promote healing and restore function thixotropic separator gel: gel contained in some vacuum tubes that forms a barrier between the cellular portion and the serum or plasma after centrifugation thoracentesis: medical procedure performed to withdraw fluids from the pleural space thrombocyte: blood platelet thrombosis: blood clot thrombus: blood clot tinnitus: ringing in the ears toddler: age classification referring to late in the first year of life continuing until the preschool years tonometer: instrument that checks intraocular pressure topical: medication applied to the skin tourniquet: device used to distend veins to assist with venipuncture toxemia: see preeclampsia transdermal patch: adhesive patch applied to the skin, impregnated with medication that is slowly released into the blood stream transient flora: bacteria on the hands that is picked up throughout the day through direct contact with items that are contaminated
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951
transischemic attack (TIA): mini-stroke Transmission-Based Precautions: precautions in addition to standard precautions that should be followed when working with patients with known highly infectious diseases transrectal ultrasound (TRUS): procedure in which an ultrasound probe is inserted into the rectum to produce images of the prostrate transurethral resection of the prostate (TURP): procedure performed on males with BPH which cuts away overgrown tissue of the prostate to facilitate urination traumatic brain injury: injury to the brain caused by trauma traumatic needle: eyed needles are packaged so that the needle is separate from the suture material requiring the person performing the suturing to thread the needle triage: sorting patients according to the extent of their injuries or illnesses; process in which things are ranked in terms of importance or priority triglyceride: neutral fat found in the blood stream that transports the fat to body tissues to be used as a source of energy trimester: time period of three months; pregnancy is divided into three trimesters trocar: sharp, pointed needle tuberculosis (TB): infection caused by Mycobacterium, a slow-advancing bacterium that commonly affects the lungs but can affect other tissue as well turbid: opaque appearance of urine tympanic membrane: thin membrane separating the external ear canal from the middle ear; eardrum tympanometer: electronic device with an attached probe that is placed snugly in the patient’s ear to determine if the middle ear is sending sound waves tympany: drum-like sound upon percussion that indicates air or gas within the related region ultrasonic cleaner: device that cleans instruments by transmitting sound waves through a cleaning fluid ultrasound: (1) diagnostic procedure that uses high frequency sound waves to produce an image of an internal body structure; (2) sound waves used to generate heat in deep tissues of the body as a method of treatment for an injury or other condition of the muscles unipolar: pertaining to one pole; augmented leads are considered unipolar because a single positive electrode is referenced against a “null point” (a point with little or no significant electronic variation) United States Department of Agriculture (USDA): department of the government responsible for executing polices on agriculture, farming and food Universal Precautions: set of guidelines developed by the CDC to protect health care workers from infectious diseases by treating all human blood and OPIM products as if they were known to be infected with bloodborne pathogens urea: nitrogenous end product of protein metabolism cleared from the blood by the kidneys into the urine
952
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GLOSSARY
urethral dilatation: procedure in which the urethra is dilated with graduated dilators due to stricture urethral orifice: opening through which urine is eliminated from the body urinalysis: physical, chemical, and microscopic analysis of urine urochrome: pigment that gives urine its color urologist: medical specialist who treats diseases and disorders of the urinary tract urology: medical specialty that involves the study of the structure, physiology, and diseases of the urinary system in both males and females and the reproductive system of males usual childhood diseases (UCD or UCHD): list of routine childhood diseases experienced by most children during the time frame that the patient was a child, such as chickenpox, mumps, measles, etc.; these are decreasing due to the immunization process vaccinations: introduction of a vaccine or toxoid to provide protection from a specific disease vacuum tube: test tube that contains a vacuum, forcing blood from the vein into the tube through aspiration validation: to communicate that you consider the patient’s feelings to be legitimate vasectomy: sterilization procedure in which the vas deferens is cut, clamped, or sealed to prevent sperm from entering the ejaculate vasoconstriction: decrease in the diameter of the blood vessels vasodilation: increase in the diameter of the blood vessels vasography: radiological procedure that is used to evaluate patency (openness) of the vas deferens and ejaculatory ducts vector: carriers such as insects or rodents that can serve as a reservoir in the chain of infection venipuncture: to pierce a vein with a needle to obtain a blood specimen ventilation: rescue breath given to a victim that has stopped breathing ventricular fibrillation (V-fib): condition in which the ventricles of the heart twitch or flutter with no organized movement; very common in adult victims of sudden cardiac arrest ventricular tachycardia (V-tach): condition in which three or more PVCs appear in a row and the heart rate ranges from 150 to 250 BPM
vertigo: disturbance in the equilibrium of the body and balance that causes the patient to be dizzy vial: a small, prefilled glass or plastic bottle that contains either a single dose or multiple doses of medication virus: submicroscopic parasites of plants, animals, and bacteria that often cause disease and require a living host in order to grow and multiply visceral pain: type of abdominal pain; occurs when the hollow organs of the GI tract forcefully contract or distend viscosity: thickness of a substance visual acuity: clearness or sharpness of vision visual learner: one who learns by reading or looking at pictures vital capacity (VC): the maximum amount of air the patient is able to inhale and exhale vital signs: traditional signs of life such as blood pressure, pulse rate, respiration, and body temperature; also referred to as cardinal signs vitamins: organic substances in the diet which are found in plants and animals and are necessary for normal growth and development void: to evacuate the bladder wandering baseline: tracing in which the baseline and leads drift over the graphing paper wave: groups or segments of electrical activity within an EKG cycle wet load: instruments that are wet after autoclaving due to condensation problems wheal: bubble of fluid under the skin that develops from an intradermal injection winged infusion: butterfly set used to collect blood from small or difficult veins work practice controls: physical and mechanical methods used in the workplace designed to protect employees from exposure to bloodborne pathogens and OPIM workstation: space in the office supplied with equipment and furnishings for one person to complete work-related duties x-ray: high-energy beam capable of penetrating the body to produce images on film
i n d e x AAMA (American Association of Medical Assistants), 3, 12, 13, 17 Abbreviations, 66–67, 281, 796, 822 ABC (airway, breathing, and circulation), 886–888, 915–917 Abdominal emergencies/pain, 304, 894 ABHES (Accrediting Bureau of Health Education Schools), 12 Abnormal laboratory results, 606 Abrasions, 914 Abscesses, 542 Abuse, 445, 468–469 Accessibility, 152–153 Accreditation, 12, 594. See also Credentialing Accrediting Bureau of Health Education Schools (ABHES), 12 Acquired immune deficiency syndrome (AIDS), 201–204 Active listening, 92, 94, 181, 444–445, 470 Acute abdominal emergencies, 894 Acute symptoms, 137 ADA (Americans with Disabilities Act), 142, 151, 152–153 Addiction, nicotine, 350, 351 Additives, 624–626, 635, 710 Adhesives/glues, surgical, 541 Adhesive strips, 541, 546–547. See also Dressings Administrative information, 42–43 Administrative versus clinical duties, 4 Adolescent care, 442–444 AEDs (automated external defibrillators), 336–337, 888–889 Agar, 710–713 Age/aging, 428, 456–460, 473 Agglutination, 747 Agonist drugs, 786
AIDS (acquired immune deficiency syndrome), 201–204 Airway, breathing, and circulation (ABC), 886–888, 915–917 Alcohol, 391 Alcohol-based hand rubs, 198–199, 217–218 Algorithms, 131, 134–135 Alkaline phosphatases, 744 Allergies, 112, 117, 199, 781, 789, 849, 858. See also Anaphylaxis Alzheimer’s disease, 461–462 Ambulatory assistive devices, 167, 489–493, 498–502 American Academy of Ophthalmologists, 300 American Association of Medical Assistants (AAMA), 3, 12, 13, 17 American Association of Orthopedic Surgeons, 504 American Cancer Society, 308, 381 American Diabetes Association, 758 American Foundation for the Blind, 152 American Geriatric Society, 473 American Medical Technologists (AMT), 3, 12, 13, 17 American Society of Clinical Pathologists, 651 American Society of Phlebotomy Technicians, 651 Americans with Disabilities Act (ADA), 142, 151, 152–153 American Translator Association, 154 Amniocentesis, 395 Amounts (symptoms), 110–111 Ampules, 844–845, 866–868 AMT (American Medical Technologists), 3, 12, 13, 17 Amylase, 744 Analgesics, 558, 901 Anaphylaxis, 789, 848, 894–895 Anesthetics, 535, 537–539 Angioplasty, 341
Animals (as drug source), 781 Anorexia nervosa, 312, 445 Anoscopes, 304–305 Antagonist drugs, 786 Antibacterial ointments, 567, 713 Antibiotics, 191, 558, 713, 715, 720–721 Antibodies, 194, 196–197, 744–748 Anticipation skills, 107, 117–118, 303 Anticoagulants, 626, 694 Antigens, 194, 196, 744–748 Antiseptics, 511 Antistreptolysin O titer, 746 Apical pulse, 234–235, 251 Appearance, personal, 10–11 Appointments, 108–110, 118–119, 122–123, 131–132, 269 Arrhythmias, cardiac, 234, 332, 334–336 Arterial blood/arterial blood gases, 359, 735–736 Arteries, 895, 896 Arthritis, 464–465, 483, 747 Artifacts, 332, 333 Asepsis, medical, 197–200, 216–219, 506–507 Asepsis, surgical. See Surgical asepsis Aspiration, 411–412, 542–543, 847, 851 Aspirin, 901 Assisted living facilities, 468 Asthma, 896–897 Athletics, 444 Atlas of urinary sediment, 666–670 Atrial fibrillation, 334–335 Attire, surgical, 561–562, 581–583. See also Personal protective equipment (PPE) Attitude, professional, 6–7 Audio learners, 180 Audiologist, 286 Audiometer/audiometry, 278, 288–289 Aural temperature, 229, 245–246, 448
954
❖
INDEX
Auscultatory gap, 241 Autoclave, 512–517, 521–524 Automated external defibrillators (AEDs), 336–337, 888–889 Automated hematology analyzers, 693–694 Auxiliary aids and services, 142, 151–152, 161 AVPU scale, 885–886 Axillary temperature, 229–230, 247–248 Babies. See Infants Bacille Calmette-Guérin (BCG) vaccine, 361 Bacitracin testing, 713 Bacteria antibacterial ointments, 567, 713 antibiotic resistance of, 715 characteristics of, 703–706 diseases related to, 716–717 identification of, 709–713 infections and, 191 microscopic examinations of, 713–715 nomenclature system for, 703 surgical asepsis and, 507–524 tuberculosis and, 359 Bandage materials/bandaging, 567–569, 912–913 Baseline values, 591 Basic metabolic panel (BMP), 737 Basophils, 688 B-cells, 194 Behavior, 5, 444–445 Bethesda system, 384 Bilirubin, 665 Billing, 39 Binge eating, 312–313 Biochemical tests, 712 Bioengineering, 781 Biohazard bags/waste, 210 Biohazard labels, 212 Biological hazards, 210, 601 Biopsy, 418 Bleeding emergencies, 895–896, 907–908, 917–918 Blind patients. See Sight impaired patients Blood. See also Blood samples; Hematology; Pulse; other blood-related entries bank, 597 bleeding emergencies, 895–896, 907–908, 917–918 cells, 680 (See also Red blood cells; White blood cells)
components of, 681–682 dialysis and, 413–415 disorders, 683 exposure control plan on, 207–212 fecal testing for, 305–306, 313–314 infection control and, 197–198, 200–206 oxygen in, 241, 356–359, 365–366 transfusions, 597, 747–748 typing, 747–748 Bloodborne diseases, 201–206 Bloodborne pathogens, 207 Bloodborne Pathogens Standard, 207, 209 Blood cells, 680. See also Red blood cells; White blood cells Blood pressure, 236–241, 252–254, 392, 433 Blood samples automated hematology analyzers, 693–694 blood typing, 747–748 capillary punctures, 636–638, 647–649 clinical chemical tests on, 734–740 coagulation tests on, 694 complete blood count (CBC) on, 682–691, 695–697 erythrocyte sedimentation rate in, 692–693, 698–699 glucose tests on, 740–743 hematology tests and, 682–699 patient response/complications, 632–634 pediatric patients and, 441–442, 449–451, 626, 636–638 profiles and panels on, 591, 595, 736–740 purpose of, 618–619 specimen handling guidelines, 638 specimen rejection, 634–636 syringe method of, 631–632, 639–641 tray set-up for, 627 urinary system and, 409 vacuum tube system, 622–626, 632, 642–644 venipuncture and, 619–634, 639–647 winged infusion (butterfly) system, 626–627, 632, 645–647 BMP (basic metabolic panel), 737
Body fluids, 111, 192, 197–212, 858–859. See also specific body fluids Body language, 86–87, 156, 157, 162, 181 Body mass index, 225–226, 443 Body parts/systems, 113–116, 266–268, 459. See also specific body parts and systems Body substance isolation, 200 Body surface area, 828–829 Body temperature, 226–232, 244–249, 434, 447–449 Bone density tests, 466, 774 Bones, injuries to, 266, 478–483, 910–911, 919–920. See also Orthopedics; Osteoporosis Boundaries, 107, 108, 130–131 Bradycardia, 234, 334 Brain, 444, 467–468, 899–900, 902–903, 905. See also Cognitive functions Breast examinations, 380, 381, 401–402 Breastfeeding, 771 Breathing. See Respiration/respiratory disorders Bronchoscopy, 353 Buccal medications, 803 Bulimia nervosa, 312, 445 Burns, 908–910 Butterfly (winged infusion) system, 626–627, 632, 645–647 CAAHEP (Commission on Accreditation of Allied Health Education Programs), 12 Calcium, 744 Callbacks, 26 Canes, 489–490, 498 Capillary punctures, 636–638, 647–649 Capillary tubes, 685–686 Carbon dioxide, 359 Carbon monoxide, 358 Carcinoembryonic antigen, 744 Cardiac arrhythmias, 234, 332, 334–336 Cardiac catheterization, 341 Cardiac profile, 739–740 Cardiologists, 322 Cardiopulmonary resuscitation (CPR), 886–888, 897, 915–917 Cardiovascular system cardiac arrhythmias in, 234, 332, 334–336 cardiac cycle and, 323–324
INDEX
CPR and, 886–888, 897, 915–917 defibrillation and, 336–337, 888–889 diagnostic testing of, 337–345 electrocardiogram and, 321–332, 342–343, 444 heart in, 322–323 myocardial infarctions, 337, 739–740, 900–901 patient screening for, 322 Caregivers, 168, 464, 468, 471–472 Cartilage, 483 Cartridge injector devices, 846, 872–874 Casts, 480–482 Catheterization, 341, 409–410, 422–424, 656 Causative agents, 191–192 CBC (complete blood count), 682–691, 695–697 CCHIT (Certification Commission for Health Care Information Technology), 54 Cell-mediated immunity, 194 Cellular telephones, 262 Centers for Disease Control and Prevention (CDC), 198, 200–202, 221 Centers for Medicare and Medicaid Services (CMS), 54, 117, 592 Centrifuge, 609–610, 626, 665, 685–686, 735 Cerebrovascular accident (CVA), 467–468, 905 Certification Commission for Health Care Information Technology (CCHIT), 54 Certifications, 12–13, 21, 54, 592–594, 619. See also Precertifications Certified Medical Assistant (CMA) credentials, 12, 13 Cervical cancer, 382 Chain of custody, 749–750 Charts, 28–30. See also Medical records Chemical disposable thermometers, 230 Chemical examinations, 662–665, 674–676 Chemical hygiene plans, 213–215 Chemical indicator strips, 511 Chemical inventory forms, 214–215 Chemicals, 212–215, 600–601, 781 Chemistry analyzers, 734 Chest circumference, 432–433 Chief complaints, 69, 108, 110
Children. See Pediatric patients Choking, 897–898 Cholesterol, 738–739 Chronic wounds, 568–569 Circumcision, 420, 442 Circumferences, 225–226, 432–433 Civil Rights Act of 1964, 151 Clamps/clamping, 530–533 Clarity of urine, 660–661 Cleanliness, 655–656, 673–674. See also Sanitization CLIA (Clinical Laboratory Improvement Amendment), 592, 616 Clinical and Lab Standards Institute (CLSI), 631–632, 638. See also Waived tests Clinical chemical tests blood typing and, 747–748 common tests, 751–752 drug testing and, 748–751 glucose testing and, 740–743, 753–754 profiles and panels of, 736–740 quality control of, 734–735 serology/immunology tests and, 744–746, 754–756 specimens for, 734–735 Clinical chemistry department, 596 Clinical diagnoses, 591, 603 Clinical equipment, 31–34. See also Equipment Clinical information, 43–51, 50 Clinical Laboratory Improvement Amendment (CLIA), 592, 616 Clinical versus administrative duties, 4 Closed wounds, 912–913 Closing procedures, 28 Closing signatures, 117 Clotting, 626, 694 CLSI (Clinical and Lab Standards Institute), 631–632, 638. See also Waived tests CMA (Certified Medical Assistant) credentials, 12, 13 CMP (comprehensive metabolic panel), 737 CMS (Centers for Medicare and Medicaid Services), 54, 117, 592 Coagulation tests, 694 Code of ethics, 3 Cognitive functions, 168, 458–462 COLA (Commission on Office Laboratory Accreditation), 594
❖
955
Cold emergencies related to, 232, 906–907 therapy, 479, 486, 496–497, 546, 912 Colleagues, 7, 25, 28 Colonoscopy, 304, 306–308 Colorectal cancer, 306–307 Colors of body fluids, 111 color blindness/color vision deficiency, 282–283, 293–294 color perception, 435 of serum and plasma, 736–737 of urine, 660–661 of vacuum tube stoppers, 624–625 Commission on Accreditation of Allied Health Education Programs (CAAHEP), 12 Communicable diseases, 195, 351–352, 359–361. See also Microbiology Communication. See also Telecommunications cultural diversity and, 154–158, 169–170 with deaf/hearing impaired patients, 142, 151–152, 160–162, 172–174 in education sessions, 180–181 language and (See Language barriers) medical records as, 39 nonverbal, 181, 429 (See also Active listening; Body language; Eye contact) with pediatric patients, 428–429 professionalism and, 9–10, 63 with senior patients, 471 with sight impaired patients, 157, 159–161, 170–172 therapeutic, 86–88 verbal, 181 Community resources, 183–186 Compassion, 8 Competency testing, 21–22 Complaints, chief, 69, 108, 110 Complete blood count (CBC), 682–691, 695–697 Complications, 397, 632–634, 856, 861–863 Comprehensive medical history, 95, 96–102 Comprehensive metabolic panel (CMP), 737 Compulsive overeating, 312
956
❖
INDEX
Computed tomography (CT) scan, 352, 771 Concierge medicine, 39, 140 Concussions, 444 Conduction loss/deafness, 286–287 Confidentiality, 8, 53, 442, 751. See also Privacy Connective tissue. See Orthopedics Consent, 66, 67, 557, 749 Constructive criticism, 6–7 Consultation reports, 49, 50, 119 Contagious infections, 351–352. See also Communicable diseases Contrast media, 768–769, 771 Contrast sensitivity testing, 283 Controlled substances, 791–795, 797 Coronary heart disease, 321, 345, 738–739 Correlation, in urinalysis, 670–672 Coworkers, 7, 25, 28 CPR (cardiopulmonary resuscitation), 886–888, 897, 915–917 Crash carts, 891–892 C-Reactive Protein, 746 Credentialing, 12–15. See also Education Creeds, 3 Critical lab values, 137–139 Criticism, constructive, 6–7 Crutches, 490–492, 499–500 Cryotherapy, 479, 486, 496–497, 546, 912 CT (computed tomography) scan, 352, 771 Cultural diversity communications and, 154–158, 169–170 eye contact and, 87 language barriers and, 88, 128 prenatal care and, 389 radiological procedures and, 768 vaccines and, 439 Culture and sensitivity tests, 709, 723–729 Cultures, 709–713 Cuts. See Wounds Cutting, instruments for, 530–531 CVA (cerebrovascular accident), 467–468, 905 Cystoscopy, 410–411 Cytology department, 597 Dates of appointment, 109–110 of disinfecting solutions, 511 expiration, 626, 663, 794, 832
of onset, 111 of specimen collection, 603 of sterilized instruments, 513–514 DEA (Drug Enforcement Administration), 791–795 Deaf patients, 142, 151–152, 160–162, 172–174, 180. See also Ear disorders/ examinations Death and dying, 471–472 Debridement, skin, 565 Defense mechanisms, 194, 196–197 Defibrillation, 336–337, 888–889 Dehydration, 470–471 Dementia, 168, 461–462 Dependability, 7 Depression, 398, 444–445, 470 Desks. See Workplace/workstations Diabetes, 465, 466, 661, 740–743, 898–899 Diagnostic imaging. See Radiology Diagnostic procedures cardiac, 337–345 documentation of, 69, 71 gastrointestinal examinations and, 306–308 in gynecology, 384, 386 male reproductive system and, 418–420 on orthopedic patients, 477–478 prenatal, 393–395 respiratory disorders and, 352–362, 364–368 urinary system and, 408–412, 422–424 Diagnostic reports, 48–49, 119, 324, 326, 352, 409 Dialysis, 413–415 Diastole, 237, 240 Diet, 304–305, 741. See also Nutrition Dieticians, 303, 310 Differential count, 687–690, 696–697 Differential diagnoses, 591 Dipsticks, urine, 661, 662–664, 670–672 Direct tests, 712 Direct transmission, 192, 201 Discharges, 31, 264, 269 Disease prevention. See Preventative health care Diseases Alzheimer’s, 461–462 bacteria-related, 716–717 common infectious, 195
commonly transmitted bloodborne, 201–206 communicable, 195, 351–352, 359–361 coronary heart disease, 321, 345, 738–739 management of, 182–186 Parkinson’s, 466–467 renal, 413–416 in senior patients, 461–462, 464–468 sexually transmitted, 384, 387 vaccinations and, 437–439 viral, 718 Disinfection, 199–200, 509–512, 519–521, 557, 559–562, 570–583. See also Sanitization; Sterilization Dislocations, 478–479, 911 Dissection, 530–531 Dobutamine stress tests, 340 Documentation. See also Medical records; Patient charts of cardiac symptoms, 338–339 competency testing and, 22 of drugs, 69–73, 112, 794, 800–801, 807–808, 848, 860 of faxes, 80–81 of in-office screening findings, 109–112, 117 of intravenous therapy, 860 laboratory regulations and, 594 in medical records, 64–80 of telephone screenings, 74–75, 137 of vaccines, 439, 807–808 Dogs, service, 160, 162 Drainage, from wounds, 567. See also Incision and drainage procedures Draping patients, 262–263, 271–273, 559 Dressings, 541, 546–547, 565–567, 583–586 Droplet transmission, 192, 201 Drug Enforcement Administration (DEA), 791–795 Drugs. See also Vaccines actions of, 782–785, 788–789, 790 administration of, 791, 798–807, 810–817, 837–855, 864–881 allergies to, 112, 117, 781, 789, 849, 858 analgesics, 558, 901 anesthetics, 535, 537–539
INDEX
antibiotics, 191, 558, 713, 715, 720–721 classifications of, 782–785, 792 complications with, 856 definition of, 780 disposal of, 794 documentation of, 69–73, 112, 794, 800–801, 807–808, 848, 860 dosage calculations, 821–830 dose response of, 786–789 education sessions on, 183, 558, 715, 788, 796 effects of, 786–789 in emergency procedures, 892 for erectile dysfunction, 421 for eye disorders, 284 interactions of, 789 intra-articular injections, 864 intravenous therapy, 858–864 labels on, 830–833 laboratory tests and, 603 math fundamentals and, 821–826 medication records, 45–46, 795, 849 medication tasks, 791, 821 medicinal uses of, 781–782 menopause and, 378 mixing two, 846, 870–872 names of, 789–791 origins of, 780–781 pharmacodynamics and, 786–789 pharmacokinetics and, 789 preparing medications, 842–846, 864–874 prescriptions, 45–46, 69–73, 140, 791–793, 795–798, 808–809, 830–833 reconstituting medications, 846, 868–870 recreational/illegal, 391, 748–751 regulations on, 780, 791–795 resistance to, 360, 715 resources on, 798–799 for respiratory disorders, 361–363, 368–369 routes of administration, 801–807, 810–817, 837, 839– 841, 848–855, 874–881 safety and, 791–795, 796, 798–801 senior patients and, 466 surgical procedures and, 558 testing for, 748–751 Duration of symptoms, 111 Duties, 4, 26–31
Dysrhythmias, 234 Ear disorders/examinations, 285–291, 297–299. See also Hearing impaired patients Ear instillation, 290, 297 Ear irrigation, 290–291, 298–299 Eating disorders, 312–313, 318, 445 Echocardiography, 340–341 Education, 9, 20–22, 40, 215, 619. See also Credentialing Education sessions/patient education adult learning and, 177–178 on antibiotics, 715 barriers to, 178 on bloodborne diseases, 205 on breast self-examinations, 401–402 on choking prevention, 897 on cholesterol, 739 on cognitive functions, 459 on collecting in-home specimens, 305, 315 communication in, 180–181 on community resources, 183–186 on diabetes, 466, 741 documentation of, 46–47, 73–74 on drugs, 183, 558, 715, 788, 796 educational materials for, 182 on EKGs, 332 on fevers, 232 on fractures and casts, 482 on gastrointestinal procedures, 307–308 on holter monitors, 340 on inhalers, 362 on laboratory test preparation, 607 on nosebleeds, 908 on nutrition, 310 on osteoporosis, 477 on Pap tests, 386 patient compliance with, 182 on postpartum period, 398 on prenatal care, 391 on prostate cancer, 421 on radiological procedures, 767–769, 775 on rheumatoid arthritis, 747 settings for, 179–180 on sprains/strains, 479 on testicular self-examinations, 418 topics of, 182–183 on urinary system disorders, 409, 411
❖
957
on vasectomy, 419 on venipuncture, 619 via telephone, 183 Electrical stimulation of muscles, 489 Electrocardiogram (EKG), 321–332, 342–343, 444 Electrocardiographs, 323–333 Electrolytes, 415 Electronic health records, 39, 52 Electronic medical records. See EMRs Electrosurgical procedures, 544–545, 559 E-mail, 81, 129–130, 141–142, 183 Emergency health history, 95–96 Emergency medical services (EMS), 131, 134–136 Emergency procedures first responder, 884–889, 915–917 for life-threatening conditions, 136, 893–907 for non-life-threatening conditions, 907–915 staff responsibilities in, 893 at urgent care centers, 889–893 Emotions, 6, 909–910 Empathy, 8 Emphysema, 350 EMRs (electronic medical records) amendments to, 53, 80 appointment scheduling with, 108, 269 certification of, 54 consultation reports in, 50, 119 creation and maintenance of, 58–60 definition of, 52 diagnostic equipment and, 326 diagnostic reports in, 49, 119 digital x-rays in, 762 drug dosage calculations in, 830 education sessions in, 47 emergency telephone calls and, 134 flow sheets in, 51, 743 graphing laboratory data in, 693 home care instructions and, 479 hospital reports in, 49 incentives to use, 54 laboratory reports in, 29, 47, 119, 138, 140, 603, 606 laboratory requisitions and, 603 maintenance and review of, 29 material safety data sheets within, 215 measurement graphs in, 433
958
❖
INDEX
EMRs (electronic medical records) (continued) medical history in, 43, 94–95 medication logs in, 795, 849 patient data transfer to hospitals, 900 patient handouts and, 471, 479, 657 patient notes in, 89, 629 pending tasks and, 27 prescriptions in, 45, 71 progress notes in, 44, 118 pros and cons of, 52–53 security of, 56 specialist referrals and, 304 specialty examinations and, 380 telephone call records in, 46 telephone screening and, 131 vital signs in, 241 Endospores, 512, 516, 703–704 Engineering controls, 208–209 Enteral medications, 801, 802–805, 810–811 Environmental hazards, 350–351 Enzymes, cardiac, 739–740 Eosionophils, 688 Epidemiology, 190. See also Infection(s) Epinephrine, 537–538, 789, 895 Episodic medical history, 95 Equipment. See also Personal protective equipment (PPE) blood pressure, 238–240 for capillary puncture, 636–637 for cardiovascular procedures, 323–333, 336–341, 344–345, 888–889 clinical, 31–34 for clinical chemical tests, 734, 739, 741, 743, 753–754 disinfection of, 557 for ear disorders/examinations, 287–291 for emergency procedures, 888–889, 891–892 for gastrointestinal screening, 304–305, 316–317 for hematologic tests, 626, 685–686, 693–694, 735 infection control and, 209–210 for in-office surgical procedures, 544–546, 555 for intravenous therapy, 858–860 laboratory testing, 608–610 parenteral medications and, 837–842
pediatric patients and, 433 for physical examinations, 259–261 for urinalysis, 661–665 for venipuncture, 619–629 for vision testing, 283–284 workstation organization and, 24 x-ray, 761–762 Erectile dysfunction, 420–421 Errors, 4, 53, 78–80 Erythrocytes. See Red blood cells Erythrocyte sedimentation rate, 692–693, 698–699 Estrogen, 375, 377–378 Ethics, 3, 442 Ethylene oxide (EtO), 512 Etiquette, 81, 129–130 Examination rooms, 24–25, 30–31, 258–261, 270–271, 378–379, 501–502, 556–559 Examinations assisting providers during, 30, 273–275, 399–400, 402–403, 476–477 breast, 380, 381, 401–402 chemical, 662–665, 674–676 ear, 285–291, 297–299 eye, 278–285, 291–296 fixed state, 713 follow-ups to, 30, 264, 269 gastrointestinal, 303–308, 313–317 gynecological, 378–384, 399–402 living state, 713–715 of male reproductive system, 416–418 microscopic, 592–594, 665–672, 674–676, 713–715 orthopedic, 476–477 physical (See Physical examinations) postpartum, 396, 398 prenatal, 388–393, 402–403 rectal, 304–306, 384, 417, 418 respiratory, 349 of senior patients, 462–464 for sports and athletics, 444 testicular, 417–418 Excisions, of sebaceous cysts, 542–543 Exercise diabetes and, 741 guidelines for, 311–312 heart rate and, 234 pediatric patients and, 443
pulmonary function testing and, 354 senior patients and, 464, 466 therapeutic, 487–489 Expiration dates, 626, 663, 794, 832 Exposure control, 207–212, 212–215. See also Personal protective equipment (PPE) Extracorporeal shock wave lithotripsy, 413 Exudates, 567 Eye contact, 86–87, 181 Eye disorders/examinations, 278–285, 291–296. See also Sight impaired patients; Vision Eye injuries, 908–909 Eye wash stations, 208, 212, 285 Fainting, 264, 905–906 Family in education sessions, 181, 182 as interpreters, 88, 155 medical history of, 98–100, 374 in patient interviews, 88, 90 privacy laws and, 134 senior patients and, 164, 462, 464, 468, 471–472 Fasting, 607, 636, 655, 739, 741 Faxes, 80–81, 140–141, 324–325 FDA (Food and Drug Administration), 310, 378, 791 Fecal testing, 304–306, 313–315, 728–729 Fetal alcohol syndrome, 391 Fetuses. See Obstetrics Fevers, 230–232, 434 Fibrillation, 334–335, 336, 888 Files. See Medical records; Patient charts; Pending files/tasks Filing of patient charts, 29, 30 First responder, 884–889, 915–917 Fixed state examinations, 713 Flexible sigmoidoscopy, 316–317 Floor management, 29–32 Flow sheets, 51, 743 Fluids, body, 111, 192, 197–212, 858–859. See also specific body fluids Fluids, from wounds, 567 Foam on urine, 659 Follicle stimulating hormones (FSH), 377 Follow-up appointments, 118–119, 122–123 Follow-up reports, 136, 144–146
INDEX
Follow-up with patients, 30, 264, 269 Fomites, 192 Food and Drug Administration (FDA), 310, 378, 791 Food labels, 310, 312 Food pyramid, 308, 310. See also Nutrition Fractures, 466, 479–483, 910–911, 919–920 Friends, 90, 134, 164 Frostbite, 906 FSH (follicle stimulating hormones), 377 Fundal height, 393 Fungi, 191–192, 720–721 Galactosemia, 442 Gastroenterologists, 303 Gastrointestinal disorders/ examinations, 303–308, 313–317 Genetic engineering, 781 Genital HPV (human papilloma virus), 387 Genogram, 98–99 Geriatrics. See Senior patients Germs. See Microorganisms Gerontologists/geriatricians, 456 Gestures. See Body language Glaucoma, 284 Gloves, 198–200, 218–219, 508, 511, 570–572, 610, 688 Glucose/glucose testing, 740–743, 753–754, 899 Glues, surgical, 541 Goggles/gowns. See Attire, surgical Good Samaritan Laws, 889 Gram stains, 705–706 Gross hearing screening, 287 Growth charts, 429–431, 433 Growth media, 710–712 Guide dogs, 160, 162 Gynecology, 374–384, 386–387, 399–402 “Halo” immobilization device, 483 Hand hygiene, 197–200, 216–219, 352, 561–562, 570–572. See also Gloves Hanging drop method, 715, 727–728 Hazardous chemicals, 212–215 Hazards, 210, 350–351, 600–601 HBV (hepatitis B virus), 200, 204–206, 211
HCV (hepatitis C virus), 204, 205 Head circumference, 432–433 Head injuries, 444, 899–900 Health and Human Services (HHS), 153–154, 592 Health care screenings. See Flow sheets Health Insurance Portability and Accountability Act. See HIPAA Health maintenance organizations, 75–76 Health records. See Electronic health records; Medical records Hearing, 287–290, 435–437, 458 Hearing impaired patients, 142, 151–152, 160–162, 172–174, 180. See also Ear disorders/ examinations Heart cardiac arrhythmias in, 234, 332, 334–336 cardiac cycle and, 323–324 coronary heart disease, 321, 345, 738–739 defibrillation and, 336–337, 888–889 diagnostic testing of, 337–345 electrocardiogram and, 321–332, 342–343, 444 heart attack, 337, 739–740, 900–901 noninvasive heart scan, 341 role in cardiovascular system, 322–323 Heart rate. See Pulse Heat, 227, 484–487, 494–495, 512–517, 906–907, 912 Height, 224, 242–243, 393, 429–431, 442–443, 446–447, 828–829 Helicobacter pylori bacteria, 745, 746 Hematocrit, 685–686, 695–696 Hematology. See also Blood; Blood samples automated hematology analyzers, 693–694 basic studies in, 682–699 blood components, 681–682 coagulation tests in, 694 complete blood count (CBC), 682–691, 695–697 definition of, 680 department, 596 erythrocyte sedimentation rate in, 692–693, 698–699
❖
959
Hematomas, 634 Hemodialysis, 413–414 Hemoglobin, 682, 683, 684–685, 742–743 Hemolysis, 635 Hemopoeisis, 680 Hemorrhaging, 895–896. See also Bleeding emergencies Hemostasis, 564 Hepatic/liver profiles, 737–738 Hepatitis hepatitis B virus (HBV), 200, 204–206, 211 hepatitis C virus (HCV), 204, 205 infection control and, 200, 204–206 Hepatologists, 303 Hernias, 416–417 HHS (Health and Human Services), 153–154, 592 HIPAA (Health Insurance Portability and Accountability Act) on answering machine messages, 140 callbacks and, 26 on disclosure to family/friends, 134 on interpreters, 154 on laboratory results, 203, 269 on medical records, 39, 54–56 on patient information, 179, 260 penalties for violation of, 56, 58 Histamine, 895 Histology department, 597 History, medical. See Medical history History of present illness, 108 HIV (human immunodeficiency virus), 200, 201–204, 746 HMIS labels, 214–215 Holter monitors, 337–339, 340, 344–345 Home care instructions, 137 Homeostasis, 226, 734 Homocystinuria, 442 Honesty/honor, 8 Hormone replacement therapy, 378 Hormones, 375–378 Hospice, 471–472, 473 Hospital admissions, 77–78, 80 Hospital laboratory, 595 Hospital reports, 49 Household measurements, 825–826 HPV (human papilloma virus), 387 Human immunodeficiency virus (HIV), 200, 201–204, 746 Humoral immunity, 194
960
❖
INDEX
Hydration, 470–471 Hydrotherapy, 487 Hygiene, personal, 166 Hyperbaric oxygen therapy, 569 Hypertension, 240, 241 Hypoglycemia, 742, 898 Hypothermia, 232, 906–907 Hypothyroidism, 442 Hypoxia, 356 Ice, 479, 486, 496–497 Immune system, 194, 196–197 Immunity, types of, 194, 196 Immunizations. See Vaccines Immunology department, 597 Immunology tests, 744–746, 754–756 Immunoreactive trypsinogen (IRT), 441 Immunosuppression, 192, 201–204 Imperial system, 825–826 Incision and drainage procedures, 542–544, 914 Indirect transmission, 192, 201 Individually identifiable health information, 54 Infants, 429–436, 441–442, 446–451, 636–638, 658, 897–898. See also Pediatric patients Infection Control Today, 588 Infection(s). See also Communicable diseases; Disinfection; Pathogens blood/body fluids and, 192, 197, 200–206 chain of, 190–193 common infectious diseases and, 195 commonly transmitted bloodborne diseases and, 201–206 contagious, 351–352 control, 197–206, 209–210, 216–219, 352, 437–439, 703 defense mechanisms against, 194, 196–197 environment and, 193 fevers and, 230–232 opportunistic, 202–204 OSHA regulations on, 204–212 stages of, 193–194 tuberculosis as, 359–361 vaccinations and, 437–439 yeast, 191–192, 720–721 Infectious waste. See Regulated waste Inflammation, 194, 196, 564, 912
Influenza, 731, 745 Informed consent, 66, 67 Inhalers, 362 Initiative, showing, 8 Injections. See also Needles; Syringes intra-articular, 864 intradermal, 839–841, 849–850, 874–875 intramuscular, 839–841, 847, 851–855, 878–879 parenteral medications by, 837 in pediatric patients, 440–441, 451–452 subcutaneous, 839–841, 847, 850–852, 876–877 Z-track method of, 855, 879–881 Injuries. See specific types of injuries In-office procedures documentation of, 69, 71 preparation for, 555–561, 570–583 solutions and supplies for, 576–580 tray set-ups for, 541–546, 556–559, 560, 574–575, 578–580 x-rays as, 763, 765 In-office screenings. See Screenings, in-office Instillations, 284, 285, 290, 294–295, 297 Institute for Safe Medication Practices (ISMP), 67 Instruments. See also Equipment; Tray set-ups care and maintenance of, 507–512, 518–521 device classification of, 510 preparation of, 560–561 sterilization of, 511, 512–517, 521–524, 560–561 types of surgical, 528–534 Insulin, 740, 830, 843, 898–899 Insurance companies, 44, 75–77, 304, 606, 607, 768 Insurance surveyors, 13, 33, 51, 134, 516, 707 Integrity, 8 International System of Units (Le Système International d’Unités), 822 Interpersonal distances, 4, 90–91, 156 Interpreters, 88, 128, 142, 152–156, 161–162, 172–173, 429 Interval health history, 95
Interviews, patient. See Patient interviews Intra-articular injections, 864 Intradermal injections, 839–841, 849–850, 874–875 Intramuscular injections, 839–841, 847, 851–855, 878–879 Intravenous pyelography (IVP), 411, 412 Intravenous therapy, 858–864 Invasive procedures, 165–166. See also Surgical procedures; Venipuncture Iodine, 561 Irrigations, 285, 290–291, 295–296, 298–299 IRT (immunoreactive trypsinogen), 441 Ishihara Method, 283, 293–294 ISMP (Institute for Safe Medication Practices), 67 IVP (intravenous pyelography), 411, 412 Jaeger chart, 282 Joint Commission (JC), 65–67, 83, 281, 554–555, 796, 822 Joints, 483, 489, 542–543. See also Orthopedics Ketones, 665 Ketonuria, 442 Kidney Foundation, 678 Kidneys, 413–416, 653, 738 Knowles, Malcolm, 177–178 KOH (potassium hydroxide) tests, 358–359, 366–368, 721 Korotkoff sounds, 238–239, 240–241 Kubler-Ross, Elisabeth, 471 Labels/labeling biohazard, 212 on drugs, 830–833 on food, 310, 312 HMIS, 214–215 specimen tubes, 635 urine containers, 654 warning, 832–833 Labor and delivery, 396 Laboratories classifications of, 594–595 departments in, 595–597, 598, 703 hazards in, 210, 600–601 personnel in, 597, 599 pharmaceutical, 781
INDEX
quality assurance in, 599 quality control in, 597, 599 requisitions for, 601–604 safety in, 600 Laboratory logs, 70, 603–604 Laboratory procedures. See also Blood samples; Specimens; Urinalysis clinical chemical tests as (See Clinical chemical tests) documentation of, 69, 70 equipment for, 608–610 gynecological, 383–385, 399–400 hematology tests as, 682–699 male reproductive system and, 418–420 patient preparation for, 606, 607 prenatal care and, 390 rationale for, 591–592 regulations on, 592–594 for respiratory disorders, 358–359, 366–368 urinary system and, 409–410, 422–424 Laboratory reports abnormal, 606 EMRs and, 29, 47, 119, 138, 140, 603, 606 follow-up on, 144–146 in medical records, 47–48, 51 pending files and, 28, 47, 137–139, 144–146 privacy issues and, 269 receipt of, 604–606 results to patients, 139–140, 203, 269, 606, 611 screening, 137–140, 144–146 Lacerations, 542, 907, 914 Language barriers in education sessions, 180 interpreters and, 88, 128, 142, 153–156 laws on, 153–154 in patient interviews, 88 reasonable accommodation for, 142 sign language and, 161–162 telephone calls and, 128 visual acuity testing and, 279, 281 Language development, 436, 437 Laser procedures, 545–546, 559 Latex, sensitivity to, 199 Learning styles, 180 Legal issues drugs and, 780, 791–795, 821, 858
emergency care and, 889 intravenous therapy and, 858 laboratory tests and, 591, 592–594 language barriers and, 153–154 medical records and, 39, 54–56, 64–65 needle safety and, 624 special needs patients and, 151–154 telephone medicine and, 132–133 x-rays and, 761 Leukocytes. See White blood cells Licensing, 12–13, 761 Lifestyle, 100–102, 466, 741 Life-threatening conditions, 136, 893–907 Ligaments, 478. See also Orthopedics Light-headedness, 264 Limited English proficiency, 153–156. See also Language barriers Lipase, 744 Lipemia, 636 Lipid profile, 738–739 Lip reading, 162, 173–174 Liquid medications, 803–804 Liquid nitrogen, 546 Listening techniques, 92, 94, 181, 444–445, 470 Liver profiles, 737–738 Living state examinations, 713–715 Location of symptoms, 110 Lubrication of instruments, 508, 518–519 Lung cancer, 350 Lungs. See Respiration/respiratory disorders Magnesium, 743 Magnetic resonance imaging, 352–353, 771–773 Maintenance of autoclave, 516 of clinical equipment, 31–34 of electrocardiographs, 328 of medical records, 29, 51–54 of microscopes, 609 of surgical instruments, 507–512, 518–521 Mammography, 381 Mantoux skin tests, 360 Masks. See Attire, surgical Material safety data sheets (MSDS), 213–215, 512, 601 Medical abbreviations. See Abbreviations
❖
961
Medical asepsis, 197–200, 216–219, 506–507 MedicAlert products, 885, 886 Medical history. See also Patient interviews collection of, 92, 94–95 comprehensive, 95, 96–102 emergency health history as, 95–96 episodic, 95 family, 98–100, 374 gynecology and, 374, 379–380 importance of, 85–86 inclusion in medical records, 43, 94–95 interval health history as, 95 obstetrics and, 388 patient history forms and, 102–104 personal, 97–98 phlebotomy and, 629 social history and, 100–102 Medical necessity, 117 Medical records. See also EMRs (electronic medical records); Patient charts abbreviations in, 66–67 addendums and amendments to, 78–80 contents of, 40–51 creation and maintenance of, 51–54 description of, 39–40 disposal of, 58 documentation in, 64–80 on exposure incidents, 212 laws affecting, 39, 54–56, 64–65 medication and immunizations in, 45–46, 807–808 ownership of, 56–57 retention of, 57–58 Medicare and Medicaid, 54, 117, 592 Medications. See Drugs Memory, 460 Men, reproductive system of, 416–421 Menopause, 375, 377–378 Menstrual cycle, 374–378 Mental health issues, 398, 444–445, 470, 909–910 Mentally impaired patients, 167–168 Metabolism, 740 Methanol, 687–688 Metric system, 822–826 Microbiology bacteria and, 703–706, 709–713, 716–717
962
❖
INDEX
Microbiology (continued) department, 596–597, 703 divisions of, 703 microorganism classification in, 702–703 microscopic examinations in, 713–715 mycology and, 720–721 parasitology and, 717, 719–720, 728–729 quality control of, 721–722 sensitivity testing, 713–714 specimen collection, 706–708, 723–729 virology and, 717–718 Microhematocrit, 685–686, 695–696 Microorganisms. See also Bacteria; Parasites/parisitology; Viruses classification of, 702–703 environment for, 193 infections and, 190 (See also Pathogens) medical asepsis and, 197 microscopic examinations of, 713–715 mycology and, 720–721 parasitology and, 192, 717, 719–720, 728–729 sensitivity testing, 713–714 specimen collection of, 706–708, 723–729 surgical asepsis and, 507–524 virology and, 717–718 Microscopes, 608–609, 613–614, 713–715 Microscopic examination, 592–594, 665–672, 674–676, 713–715 Milking instruments, 508 Minerals, 308, 781 Modeling behavior, 5 Molds, 721 Mononucleosis, 745, 756 Motivation, 177–178, 180 Motor development, 435–436 MRI (magnetic resonance imaging), 352–353, 771–773 MSDS (material safety data sheets), 213–215, 512, 601 Mucosal membrane medications, 805–806 Multisample needles, 623, 624 Muscles. See also Orthopedics electrical stimulation of, 489 injuries to, 477–478, 910–912 intramuscular injections, 839–841, 847, 851–855, 878–879 rehabilitation of, 483–489
Musculoskeletal system. See Orthopedics Mycology, 720–721 Myocardial infarction, 337, 739–740, 900–901 National Fire Protection Association, 214–215 National Institute for Allergy and Infectious Disease, 371 National Institute of Arthritis, Musculoskeletal, and Skin Diseases, 504 National Institute of Mental Health, 454 National Institute on Deafness and Other Communication Disorders, 300 National Patient Safety Goals, 65, 67, 555, 796, 801 Near visual acuity testing, 282, 292–293 Nebulizers, 361–362, 368–369 Neck injuries, 899–900 Needles butterfly, 627 infection control and, 200–201, 209 multisample, 623, 624 parenteral medications and, 838–842, 845–846, 849, 850–851 safety features of, 620–621, 623–624, 842 suture, 539–540 for venipuncture, 620–622, 623, 627, 634 Needlestick Safety and Prevention Act of 2000, 209 Nephrologists, 408 Nerve deafness, 287 Neutrophils, 688 Nicotine addiction, 350, 351 Night eating syndrome, 313 Noninvasive heart scan, 341 Non-life-threatening conditions, 907–915 Nonverbal communication, 181, 429. See also Active listening; Body language; Eye contact Normal flora, 190, 197, 709 Nosebleeds, 907–908 Nuclear medicine, 773–774 Nurse practitioners. See Providers Nursing home reports, 49 Nursing homes, 468
Nutrition, 308–312, 443, 466, 470–471. See also Diet; Eating disorders Obesity, 442–443 OB-GYN, 374. See also Gynecology; Obstetrics Obstetrics labor and delivery, 396 postpartum period and, 396, 398 pregnancy complications and, 397 pregnancy tests, 744, 754–755 prenatal care and, 387–395, 402–403 prenatal diagnostic testing and, 393–395 Rh factor and, 748 x-rays and, 767 Occupational Exposure to Hazardous Chemicals in the Laboratory Standard, 600 Occupational Safety and Health Administration, 204–215, 221, 600, 620 Occupational therapists, 484 Odor of urine, 659 Offices. See Workplace/workstations Older adults. See Senior patients Open access plans, 76 Opened-container life, 511 Opening procedures, 26, 28 Open wounds, 564–569, 907, 914–915 Ophthalmologists, 278 Ophthalmoscope, 278, 279 Opportunistic infections, 202–204 Opticians, 279 Optometrists, 278–279 Oral medications, 802–804, 810–811 Oral temperature, 228, 244–245 Organization, 20–26 Orthopedics ambulatory assistive devices and, 167, 489–493, 498–502 diagnostic procedures in, 477–478 emergency musculoskeletal injuries, 910–912, 919–920 rehabilitation and, 483–489, 494–497 screenings/examinations in, 476–477 specialists in, 476 strains, sprains, fractures and dislocations, 466, 477–483, 910–911, 919–920 surgical procedures in, 483 Web sites on, 504
INDEX
Orthopedists, 476 OSHA (Occupational Safety and Health Administration), 204–215, 221, 600, 620 Osteoporosis, 465–466, 477, 774 Otorhinolarygnologist, 286 Otoscope, 278 Out guides, 30 Oxygen, 241, 350, 356–359, 363, 365–366, 569 Pagers, 262 Pain, 111, 240–241, 304, 631, 862 Palliative care, 471 Panels. See Profiles Panic values, 606 Pap tests, 378–379, 382–385, 399–400 Parasites/parisitology, 192, 717, 719–720, 728–729 Parenteral medications administration of, 811–817, 837–848, 864–881 complications, 856 definition of, 802 guidelines for, 846–848 immunizations as, 856–858 intra-articular injections, 864 intravenous therapy and, 858–864 mixing two, 846, 870–872 preparing, 842–846, 864–874 reconstituting, 846, 868–870 routes of administration, 837, 839–841, 848–855, 874–881 types of, 805–807 Parents, 5. See also Family Parkinson’s disease, 466–467 Paroxysmal atrial tachycardia, 334–335 Pathogens. See also Infection(s); Microorganisms blood/body fluids and, 192, 197, 200–206 bloodborne, 207 commonly transmitted bloodborne diseases and, 201–206 defense mechanisms against, 194, 196–197 environment for, 193 fevers and, 230–232 identification and isolation of, 709–713 infection control and, 197–200 microscopic examinations of, 713–715
mycology and, 720–721 parasitology and, 192, 717, 719–720, 728–729 sensitivity testing, 713–714 types of, 190–192 virology and, 717–718 Pathologists, 597 Patient charts, 28–30. See also Medical records Patient education. See Education sessions/patient education Patient examination rooms. See Examination rooms Patient intake, 224 Patient interviews, 86–94, 102–104. See also Medical history Patient notes, 89, 629 Patients. See also specific categories of patients (i.e., pediactric patients) addressing by name, 223, 224 blood collection and, 632–634 compliance of, 182 discharge of, 31 examination follow-ups with, 30, 264, 269 identification of, 65, 603, 628–629, 800 judging, 112 laboratory procedure preparation for, 606, 607 medical records of (See Medical records) positioning and draping of, 262–263, 271–273, 392, 559, 629–630, 763–764, 853–855, 889, 903–905 preparing for providers, 30, 260, 388–389 preparing for radiology, 767–769 privacy regulations for (See HIPAA) professionalism with, 2–15, 63, 178 safety of, 260, 262, 554–555, 767 test result reporting to, 139–140, 203, 269, 606, 611 Peak flow testing, 354–356 Pediatric patients abuse of, 445 adolescent care in, 442–444 age classifications of, 428 blood samples/screenings from, 441–442, 449–451, 626, 636–638 choking, 897–898 circumcision and, 420, 442
❖
963
communication with, 428–429 development of, 434–436 drug dosages for, 828–830 infant/toddler measurements in, 429–435, 446–449 injections for, 440–441, 451–452 mental health issues in, 444–445 modeling parent behavior, 5 screenings of, 436–437, 441–442, 449–451 sudden infant death syndrome in, 442 urine collection from, 658 vaccinations for, 437–439 visual acuity testing and, 279, 281 working with, 164–166 Pelli-Robson chart, 283 Pelvic examinations, 382–385, 399–400 Pending files/tasks, 25–28, 47, 137–139, 144–146 Peptic ulcers, 745, 746 Percutaneous suprapubic bladder aspiration, 411–412 Peritoneal dialysis, 414–415 Personal health records, 39 Personal medical history, 97–98 Personal protective equipment (PPE). See also Gloves; Surgical attire blood samples and, 688 disinfectants and, 511 emergency care and, 885, 887 infection control and, 192, 200–201, 207–208 radiation and, 766–767 waste disposal and, 210–211 Pharmacodynamics, 786–789 Pharmacokinetics, 789 Pharmacology, 780. See also Drugs Phenylketonuria (PKU), 441, 449–451 Phlebotomy capillary punctures, 636–638, 647–649 patient response/complications, 632–634 purpose of, 618–619 specimen handling guidelines, 638 specimen rejection, 634–636 syringe method of, 631–632, 639–641 tray set-up for, 627 vacuum tube system, 622–626, 632, 642–644 venipuncture, 619–634, 639–647
964
❖
INDEX
Phlebotomy (continued) Web sites on, 651 winged infusion (butterfly) system, 626–627, 632, 645–647 Phosphorous, 743–744 Physical disabilities, 152–153, 166–167. See also Ambulatory assistive devices Physical examinations assisting provider during, 273–275 equipment used during, 259–261 examination room preparation for, 258–261, 270–271 patient assessment during, 264–269 patient positioning and draping for, 262–263, 271–273 patient preparation for, 260, 262–263 purpose of, 44 urinalysis and, 659–662, 674–676 Physical hazards in laboratories, 601 Physical therapists, 484 Physical therapy, 483–489 Physician assistants. See Providers Physicians. See Providers Physician’s Desk Reference, 798, 799 Physician’s office laboratories (POLs), 594–595, 653, 682, 685, 692–694 PKU (phenylketonuria), 441, 449–451 Plants (as drug source), 780–781 Plasma, 681, 735, 736 Platelets, 682, 684 Point-of-care testing (POCT), 595, 636 Poisonings, 901–902, 903 Policies and procedures, 22–23, 599 POLs (physician’s office laboratories), 594–595, 653, 682, 685, 692–694 Portals of entry/exit, 192 Positioning patients in emergency situations, 889 for in-office surgical procedures, 559 for intramuscular injections, 853–855 for physical examinations, 262–263, 271–273 prenatal care and, 392 seizures and, 903 shock and, 904–905
syncope episodes and, 905 for venipuncture, 629–630 for x-rays, 763–764 Postpartum period, 396, 398 PPE. See Personal protective equipment (PPE) PPMP (provider-performed microscopy procedures), 592–594 Precertifications, 76–77, 78 Preeclampsia, 391 Pregnancy. See Obstetrics Premature atrial contractions, 334–335 Premature ventricular contractions, 334–336 Prenatal care, 387–395, 402–403. See also Obstetrics Prescriptions, 45–46, 69–73, 140, 791–793, 795–798, 808–809, 830–833. See also Drugs Preventative health care, 29, 182–186, 304, 374 Prioritization, 27, 32, 144. See also Triaging Privacy, 26, 54–57, 442, 751. See also Confidentiality; HIPAA Problem lists, 40, 41 Problem-oriented medical records, 40 Proctologists, 303 Proctoscopes, 304–305 Procurement stations, 595 Professionalism, 2–15, 21, 63, 178 Professional liability, 64–65 Proficiency testing, 600 Profiles, 591, 596, 736–740 Progress notes in-office screenings and, 118–119, 122–123 in medical records, 40, 44, 45, 69, 118 medication entry in, 800 patient instructions in, 139 signatures in, 117 Prostate, 417, 418, 420, 421, 744 Prostate specific antigen (PSA), 744 Protected health information, 54–56 Proteins in urine, 665 Prothrombin time (PT level), 694 Protocols, 23, 117–118 Provider-performed microscopy procedures (PPMP), 592–594 Providers. See also Specialists assessments by, 118, 264–269 assisting with examinations, 30, 273–275, 399–400, 402–403, 476–477
assisting with surgical procedures, 562–563 cardiovascular system and, 322 contact information for, 602 ear disorders and, 286 eye disorders and, 278–279 female reproductive system and, 374 gastrointestinal disorders and, 303 in laboratories, 597, 599 in musculoskeletal system disorders, 476, 484 pending files/tasks and, 25–26 preferences of, 23 pulmonary disorders and, 349 radiological and diagnostic imaging and, 760 senior patients and, 456 urinary and male reproductive systems and, 407–408 Proxemics, 4, 90–91, 156 PSA (prostate specific antigen), 744 PT (prothrombin time) level, 694 Puberty, 443–444 Public Health Departments, 703 Pulmonary disorders. See Respiration/ respiratory disorders Pulmonary function testing, 353–355, 364–365 Pulmonologists, 349 Pulse, 232–235, 249–251, 356, 393, 434–435, 886–887 Pulse oximetry testing, 241, 356–359, 365–366 Pulse pressure, 237 Punctures, 914–915. See also Capillary punctures Pyrexia. See Fevers Quality assurance, 516, 599, 616 Quality control, 597, 599, 616, 658–659, 663–664, 721–722, 734–735 QuantiFERON-TB Gold Test, 360–361 Questioning techniques, 91–93, 113–116, 181 Radial pulse, 234–235, 249–250 Radiation therapy, 774–775 Radiology computed tomography (CT) scan and, 352, 771 medical assistant’s role in, 762–763 MRIs and, 352–353, 771–773 nuclear medicine and, 773–774
INDEX
overview of, 760–761 procedures outside office, 769–770 radiation therapy, 774–775 respiratory disorders and, 352–353 scheduling of, 767–769 ultrasounds and, 340–341, 393–395, 418, 486–487, 773 x-rays, 352, 381, 411, 412, 760–767 Rapid tests, 713–714, 725–726, 744–745, 754–756 Reagent test strips, 662–664, 670–672 Receptors, 786 Record keeping. See Documentation Records. See also EMRs; Medical records electronic health, 39, 52 medication, 45–46, 795, 849 on OSHA and MSDS training, 215 personal health, 39 Recovery position, 889 Rectal examinations, 304–306, 384, 417, 418 Rectal medications, 803, 805, 815–817 Rectal temperature, 228–229, 447–448 Red blood cells, 681–682, 684, 689–690, 692–693, 698–699, 747–748 Reductions, 479–480 Reference laboratories, 594–595 Referrals, 75–76, 77, 304 Reflexes, 435 Refractive disorders, 278–280 Refractometers, 662 Refusal to Follow Medical Advice, 66, 68, 135–136 Registered Medical Assistant (RMA) credentials, 12, 13 Registrations, 12–13 Regulated waste, 210 Regulations, 592–594, 624, 780, 791–795. See also HIPAA; Legal issues Rehabilitation, 467–468, 483–489, 494–497 Religion, 439, 442 Renal diseases, 413–416 Renal profile, 738 Reports. See Consultation reports; Diagnostic reports; Follow-up reports; Laboratory reports; Therapeutic reports
Reproductive systems female (See Gynecology; Obstetrics) male, 416–421 Requisitions, laboratory, 601–604 Reservoirs of infections, 192 Resident flora, 190, 197, 709 Resources, community. See Community resources Respiration/respiratory disorders breathing emergencies and, 886–888, 896–898, 915–917 CPR and, 886–888, 897, 915–917 diagnostic testing for, 352–362, 364–368 medication for, 361–363, 368–369 oxygen administration for, 363 in pediatric patients, 434–435, 442 risk factors for, 350–352 screening for, 349 vital signs and, 235–237, 249–250 Reuse life, 511 Rheumatoid arthritis, 747 Rheumatoid factor, 746 Rh factor, 748 Rhythm strips, 331 Rickettsiae, 192 Rinne tests, 287–288 RMA (Registered Medical Assistant) credentials, 12, 13 Roentgen, Wilhelm, 760 Safety of capillary tubes, 685–686 drugs and, 791–795, 796, 798–801 at emergency scenes, 885 in laboratories, 600 of needles, 620–621, 623–624, 842 of patients, 260, 262, 554–555, 767 specimen collection and, 706–708 x-rays and, 765–767 Saline, 561 Sanitization, 199, 352, 507–508, 518–519, 561–562, 570–583. See also Disinfection; Sterilization Sanitizer, 198–199, 217–218 Scar tissue, 564–565 Schedules, 20–21, 437–438 Screening lab reports, 137–140, 144–146 Screenings, health care. See Flow sheets
❖
965
Screenings, in-office boundaries during, 107, 108 for cardiovascular system, 322 for ear disorders/examinations, 286 education sessions on, 183 for eye disorders/examinations, 279–280 of female reproductive system, 374–375 follow-up appointments and, 118–119, 122–123 for gastrointestinal disorders/ examinations, 303 for male reproductive system, 416–417 medical assistant role in, 108–117 of musculoskeletal system, 476–477 of pediatric patients, 436–437, 441–442, 449–451 prenatal care and, 392–393 procedures for, 120–121, 224 progress notes for, 118–119, 122–123 protocol of, 117–118 provider assessment in, 118, 264–269 for respiratory disorders, 349 of senior patients, 462–464 for urinary system, 408 Screenings, telephone, 74–75, 131–137, 143–144 Screening tables. See Algorithms Sebaceous cysts, 542–543 Security of patient health data, 54, 56. See also Privacy; Safety Sediment, 665–670, 692–693, 698–699 Seizures, 902–903 Self-examinations, 183, 380, 381, 401–402, 417–418 Senior patients aging in, 456–460 blood samples from, 626, 636–638 cognitive functions in, 168, 458–462 diseases in, 461–462, 464–468 examinations of, 462–464 exercise for, 464, 466 sexually transmitted diseases in, 387 societal issues and, 468–472 Web sites on, 473 working with, 163–164 Sensitivity testing, 713–714
966
❖
INDEX
Sensory development, 435–436 Sensory organs, 180, 457–458, 459 Serology tests, 744–746, 754–756 Serum, 734–737 Service, equipment. See Maintenance Service, professional, 10, 12 Service dogs, 160, 162 Sexually transmitted diseases (STDs), 384, 387 Sexual maturation, 443–444 Sharps/sharps containers. See Needles Shaving, 559–560 Shelf life, 511, 513–514 Shingling method, 47–48 Shock, 898–899, 903–905, 920–921 Sickle cell anemia, 441, 683 Side effects, 789, 832 SIDS (sudden infant death syndrome), 442 Sight impaired patients, 152, 157, 159–161, 170–172, 180. See also Eye disorders/ examinations; Vision Sigmoidoscopy, flexible, 316–317 Signal dogs, 162 Signatures, in medical records, 117 Sign language, 161–162 Sinus bradycardia, 334 Sinus tachycardia, 334 Size (symptoms), 111 Skin closing/suturing, 538–541, 546–550 (See also Dressings) debridement of, 565 intradermal injections, 839–841, 849–850, 874–875 Mantoux skin tests, 360 medications applied to, 806–807, 811–815 skin-prep procedures, 559–560, 573–574 wound care and, 564–569, 583–586 Sleep apnea, 361, 442 Smoking, 350, 351, 358, 391, 442 Snellen chart, 279–280, 291–292 SOAP notes (subjective, objective, assessment, plan notes), 40, 41 Social history, 100–102 Societal issues (senior patients), 468–472 Solutions, 535–541, 561, 578–580 Source-oriented medical records, 40 Specialists blood sample collection by, 618–619
on cardiovascular system, 322 on ear disorders, 286 on eye disorders, 278–279 on female reproductive system, 374 on gastrointestinal disorders, 303 in laboratories, 597, 599 medical records and, 49, 50 on musculoskeletal system disorders, 476, 484 on pulmonary disorders, 349 on radiological and diagnostic imaging, 760 referrals to, 75, 304 on senior patients, 456 on urinary and male reproductive systems, 407–408 Special needs patients cultural diversity and, 154–158 legal issues and, 151–154 mentally impaired patients as, 167–168 physically disabled patients as, 166–167 senior patients as, 163–164 sight impaired patients as, 157, 159–161 Specific gravity of urine, 661 Specimens. See also Blood samples; Urinalysis centrifuge and, 609–610, 626, 665, 685–686, 735 chain of custody for, 749–750 for clinical chemical tests, 734–735 collection of, 595, 606–607, 611–612, 654–658, 673–674, 706–708, 719, 723–729 microscopes and, 608–609, 613–614, 713–715 requirements for, 598 requisition forms with, 602–603 Speech reading, 162, 173–174 Sphygmomanometer, 239–240 Spinal cord injuries, 900 Spirometry, 353–355, 364–365 Splints, 481–482, 911–912, 919–920 Spores, 512, 516, 703–704 Sports, 444 Sprains, 478, 479, 911 Sputum tests, 358–359, 366–368 Stains/staining, 688, 705–706 Standard Precautions, 200–201, 202 Standing orders, 117–118 Staples, surgical, 540–541, 544, 548–550
STDs (sexually transmitted diseases), 384, 387 Steam under pressure, 512–517 Stem cells, 483, 680 Stereotypes, 156–157 Sterile conscience, 554 Sterilization, 200, 511–517, 521–524, 557, 560–561, 574–575. See also Disinfection; Sanitization Stethoscope, 238–239, 462 Strains, 477–478, 479, 911 Streptococcus, 712–714, 725–726 Stress tests, 339–340 Strokes, 467–468, 905 Study time, 20–21 Subatmospheric pressure device, 569 Subcutaneous injections, 839–841, 847, 850–852, 876–877 Sublingual medications, 803 Sudden infant death syndrome (SIDS), 442 Sugar in urine, 665 Suicide, 445, 470, 471 Supplies. See also Tray set-ups for capillary puncture, 636–637 for emergency procedures, 891–892 for intravenous therapy, 858–860 for minor surgeries, 535–541, 555–561, 576–577 parenteral medications and, 837–842 for urinalysis, 661–664 for venipuncture, 619–629 workstation organization and, 24 Support groups, 184 Surgical adhesives/glues, 541 Surgical asepsis infection control and, 197 instrument care and maintenance, 507–512, 518–521 sterilization and, 511, 512–517, 521–524, 560–561 Surgical attire, 561–562, 581–583. See also Personal protective equipment (PPE) Surgical cards, 556–558 Surgical instruments. See also Tray set-ups care and maintenance of, 507–512, 518–521 device classification of, 510 preparation of, 560–561 sterilization of, 511–517, 521–524, 560–561 types of, 528–534
INDEX
Surgical procedures assisting provider during, 562–563 consent for, 557 in-office preparation for, 555–561, 570–583 in-office tray set-ups, 541–546, 556–559, 560, 574–575, 578–580 instruments for (See Surgical instruments) orthopedic, 483 solutions and supplies for, 535–541, 555–561, 576–580 Susceptibility to infections, 192 Suture materials, 538–540, 544, 548–550 Swelling, 479, 912 Symptoms, 108, 110–112, 131, 136, 137, 230–232 Syncope episodes, 264, 905–906 Synthetic drugs, 781 Syphilis, 745 Syringes, 622–623, 631–632, 639–641, 838–839, 842–846, 870–872 Systems, body. See Body parts/ systems Systole, 236–237, 240 Tachycardia, 234, 334–335, 336 Tactfulness, 7–8 Tactile learners, 180 Tasks (task lists/boxes), 26–31, 46, 47. See also Pending files/tasks Taste, sense of, 458 TB (tuberculosis), 359–361 T-cells, 194, 201–202 Telecommunications, 127–130. See also E-mail; Faxes; Telephone calls; Video conferencing Telecommunications device for the deaf (TDD), 142, 152 Telecommunications Relay Services, 152 Telephone calls education sessions via, 183 etiquette for, 129 during examinations, 262 laboratory reports via, 139–140 language barriers and, 128 prescriptions via, 140 reports of, in medical records, 46, 74–75 screening, 74–75, 131–137, 143–144 Telephone medicine, 130–137
Teletypewriter (TTY), 142, 152 Temperature. See also Cold; Heat body, 226–232, 244–249, 434, 447–449 of drugs, 799 emergencies related to, 906–907 of examination rooms, 30 reagent test strips and, 663 specimen handling and, 635 thermal modalities and, 479, 484–487, 494–497, 546, 912 Temporal thermometer, 230, 248–249, 434, 448 Tendons, 478, 631. See also Orthopedics Testicular self-examinations, 417–418 Tetanus shots, 542 Thanatology, 471 Therapeutic communication, 86–88 Therapeutic doses, 786–789 Therapeutic exercise, 487–489 Therapeutic heat, 484–487, 494–495, 912 Therapeutic reports, 49 Thermal modalities, 479, 484–487, 494–497, 546, 912 Thermometers, 228–230, 248–249, 434, 447–448 Thermotherapy, 484–487, 494–495, 912 Thoracentesis, 359 Throat specimens, 713–714, 725–726 Thrombocytes, 682, 684 Thyroid profile, 740 TIA (transischemic attacks), 905 Time anaphylaxis and, 894 of appointment, 109–110 duration of symptoms and, 111 management, 20–22, 29–31, 32 of specimen collection, 603, 635, 654–655, 657, 663 Toddlers, 429–435, 434–436. See also Pediatric patients Topical medications, 806, 811–813 Touching, in therapeutic environment, 87, 88 Tourniquets, 619–620, 630 Toxemia, 391 Traction, 481 Transdermal patches, 806–807, 813–815 Transfusions, blood, 597, 747–748 Transient flora, 197–198 Transischemic attacks (TIA), 905
❖
967
Translators. See Interpreters Transmission, 192, 201, 359–360 Transmission-Based Precautions, 201 Transplantation, 415–416 Transrectal ultrasound (TRUS), 418 Transurethral resection of the prostate (TURP), 420 Traumatic brain injuries, 444, 899–900 Tray set-ups, 541–546, 556–559, 560, 574–575, 578–580, 627 Treadmill stress tests, 339–340 Triaging in-office, 130 life-threatening conditions and, 893–907 non-life-threatening conditions, 907–915 telephone, 130–133 Triglycerides, 739 TRUS (transrectal ultrasound), 418 TTY (teletypewriter), 142, 152 Tuberculosis (TB), 359–361 Tuning fork screening, 287–288 Turbidity of urine, 660–661 TURP (transurethral resection of the prostate), 420 Tympanometer/tympanometry, 288, 290 Ulcers, peptic, 745, 746 Ultrasonic cleaners, 507–508 Ultrasounds, 340–341, 393–395, 418, 486–487, 773 Universal Blood and Body Fluid Precautions, 200–201 Urgent care centers. See also Emergency procedures description of, 889–893 life-threatening conditions in, 893–907 non-life-threatening conditions in, 907–915 Urinalysis chemical examination and, 662–665, 674–676 clinical chemical tests and, 744, 749, 754–755 composition of urine and, 653–654 confirmatory tests and, 664–665 department, 596 glucose testing and, 741–742 microscopic examination and, 665–672, 674–676 physical examination and, 659–662, 674–676
968
❖
INDEX
Urinalysis (continued) quality control in, 658–659, 663–664 routine, 659–672, 674–676 specimen collection for, 654–658, 673–674, 723–724 Urinary system, 408–416, 422–424 Urologists, 407–408 U.S. Pharmacopecia/National Formulary, 798 USDA (United States Department of Agriculture), 308–309 US Drug Enforcement Administration, 791–795 US Food and Drug Administration, 310, 378, 791
Vital signs, 226–241 blood pressure, 236–241, 252–254, 392, 433 pain assessment, 111, 240–241, 862 in pediatric patients, 433–435, 447–449 pulse, 232–235, 249–251, 356, 393, 434–435, 886–887 pulse oximetry, 241, 356–359, 365–366 respiration, 235–237, 249–250 of senior patients, 462–463 temperature, 226–232, 244–249, 434, 447–449 Vitamins, 308
Vaccines for adults, 856–857 allergies and, 781 contraindications and precautions in, 857–858 documentation of, 439, 807–808 EMRs and, 29 for hepatitis B virus, 206, 211 HPV (human papilloma virus), 387 against infections, 196 for pediatric patients, 437–439 for tuberculosis, 361 types of, 196–197 Vacuum tube system, 622–626, 632, 642–644 Vasectomy, 419–420 Vasography, 418 Vectors, 192 Veins, 630–631, 895 Venipuncture, 619–634, 639–647 Ventricular fibrillation, 336, 888 Ventricular tachycardia, 336 Verbal communication, 181. See also Communication Vials, 843–844, 846, 864–866 Video conferencing, 142 Viruses, 191, 507–524, 717–718 Visibility, of medical assistant, 4 Vision, 435, 436, 458. See also Eye disorders/examinations; Sight impaired patients Visual acuity testing, 279–284, 291–294, 436 Visualization instruments, 530, 533–534 Visual learners, 180
Waist circumference, 225–226 Waived tests, 592–593, 739, 745, 756 Walkers, 491, 493, 500–501 Warning labels, 832–833 Water, 487, 507, 742 Waterproof drapes, 559 Weber tests, 287–288 WebMD, 300 Web sites of AAMA, 17 of American Academy of Ophthalmologists, 300 of American Association of Orthopedic Surgeons, 504 of American Cancer Society, 308 of American Diabetes Association, 758 of American Foundation for the Blind, 152 of American Geriatric Society, 473 of American Society of Phlebotomy Technicians, 651 of AMT, 17 of CDC, 221 on drugs, 789, 818 on eating disorders, 318 on family medical history, 100 of Food and Drug Administration, 310 on food and nutrition, 308 of hospice, 473 for Infection Control Today, 588 on influenza viruses, 731 of Joint Commission, 83 for Kidney Foundation, 678 of National Institute for Allergy and Infectious Disease, 371
of National Institute of Arthritis, Musculoskeletal, and Skin Diseases, 504 of National Institute of Mental Health, 454 of National Institute on Deafness and Other Communication Disorders, 300 of OSHA, 221 on parasites, 719 on quality assurance and control, 616 on sexually transmitted diseases, 387 of WebMD, 300 for World Health Organization, 439 Weight drug dosages and, 828–830 measurements, 224–226, 242–243 of pediatric patients, 430, 431–432, 442–443, 446–447 of senior patients, 470 Wet mounts, 715, 727–728 Wheelchairs, 167, 493, 501–502 White blood cells, 682, 684, 687–690 Winged infusion (butterfly) system, 626–627, 632, 645–647 Women, reproductive system of. See Gynecology; Obstetrics Wong-Baker FACES Pain Rating Scale, 111 Working the floor, 29–32 Workplace/workstations, 22–26. See also Colleagues Work practice controls, 208–209 World Health Organization, 439 Wounds care of, 564–569, 583–586 chronic, 568–569 closing/suturing, 538–541, 546–550 emergency treatment of, 912–915 laceration repair, 542 open, 564–569, 907, 914–915 wound specimens, 726–727 Wraps, sterilization, 513–514 X-rays, 352, 381, 411, 412, 760–767 Yeast infections, 191–192, 720–721 Z-track method of injection, 855, 879–881
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