Chapter 13 Beginning the Patients Record Screening Screening is the process of obtaining information from patients to determine their medical condition The French word triage means to sort and to prioritize First priority(red flags): Chest pain, severe
bleeding, head injury, poisoning, shock, and some burns Phone Screening The medical assistant who speaks to the patient over the phone must have knowledge of: Medical Terminology Anatomy and Physiology Diseases and disorders Emergency procedures Medications
And they must use: Communication skills Problem-solving Decision-making Compassion Self-control Patients Understanding Phone Screening Taking information regarding patients condition by phone requires careful listening
and thorough questioning to ascertain the nature and the extent of the problem This will help you determine how much time the physician needs with that patient or how soon the patient needs to be seen or called back In-Person Screening Taking to a patient one-on-one and asking questions about his/her personal condition requires professional communication skills and the assurance of privacy
This is used for screening and triaging The purpose of the screening is to help patients focus on their main concern, called the chief complaint(ex: cough, fever, chest pain, physical, knee injury ect.) In-Person Screening Information you receive from patients is based upon symptoms they feel which are subjective Subjective: symptoms or sensations are those that only the patient can perceive, such as pain, dizziness, itching, or numbness
Information or symptoms that can be observed, such as swelling, bruising, vital signs, and physical findings, are known as objective In-Person Screening Many physician use a method called SOAP notes for recording patients data S= Subjective O= Objective A= Assessment P= Plan
Factors Influencing Screening Ensure Privacy: Close the door Be aware of your biases: all patient must be treated with respect Establish a relaxed atmosphere: Introduce yourself, sit at eye level Be aware of you nonverbal messages: eye rolling, looking at the clock Be sure the patient understands: Do not use medical terminology Allow the patient to talk: dont interrupt Listen Nonverbal communication: watch for patients body language:
embarrassment ; not understanding Conducting The In-Person Screening What is done by the medical assistant during the in-person screening will be determined by the employing physician Some prefer that you conduct only the chief complaint, others want all preliminary questioning done before the exam Conducting The In-Person Screening Some offices will mail out the
preliminary forms, others will ask the patient to come in 15 minutes early to complete this form You will need to look over the form to for the chief complaint, then have the patient describe this complaint in details(this will help you determine the next step. Ex: sore throat- you will obtain a rapid strep culture; pain with urination, you will need to obtain a urine specimen)
Conducting The In-Person Screening When the patient has identified all the complaints and together you have determined the specifics of the symptoms, you can then summarize the results of your screening Record the CC(chief complaint) Example: 8/6/2011 CC: RLQ pain, intermittent x 3 days, nausea, no vomiting or diarrhea. Some relief by lying
down. G. Jenks, MA Body Measurements Body measurements refers to height, weight, vital signs, and the circumference of head, chest, or abdomen of infants This is extremely important with infants and children to ensure their proper growth and development With adults, height reduction could indicate the presence of osteoporosis. A rapid weight gain could signal fluid retention Measurement of vital signs provides essential information
regarding the function of the circulatory and respiratory systems and helps to monitor any disease or conditions Head and Chest Circumference OFC- occipital- frontal circumference is measured above the infants ears(measured up to 3 years old) Chest circumference is measured just below the nipple line When measuring an infants length, apply gentle pressure to straighten the legs Height and Weight You must be familiar with
a balance beam scale The height bar is calibrated in inches Measuring and Weight the Patient When you take a patients weight and height, have the patient remove their shoes and any heavy objects(coats, handbags) Check the balance on the scale, needs to be at 0. With height; raise the height bar above the patients estimated height and extend the measuring bar, move the bar down as needed, avoid the possibility of striking the
patient The patient should always face away from the scale with the back to the height bar Height is measured mostly in inches Inches to feet
How mach inches are in a foot? 12 How many feet is 60 inches? 5 feet How many feet is 46 inches? 3 feet 10 inches How many feet is 70 inches? 5 feet 10 inches
Vital Signs Vital signs(cardinal signs) are used by health care personnel to identify the measurement of body functions that are essential to life The four vital indicators are: 1. Temperature 2. Pulse 3. Respiration 4. Blood Pressure The correct measurement of vital signs is extremely important Never-ever estimate the measurement
Temperature The temperature of the body indicates the amount of heat produced by the activity of changing food into energy Conditions affecting body heat include metabolic rate, time of day, and amount of activity(sweating) Not all people have the same normal temperature An average normal oral temperature is 98.6 A person with a temperature above normal is said to be febrile A person with a normal temperature is said to be afebrile
Temperature The accurate measurement of temperature can help the physician make a diagnosis Average Oral Axillary Rectal normal 98.6 97.6 99.6 temperature: Range: 97.6- 99.6 96.6-98.6 98.6-100.6 Page 645
Temperature The temperature regulating center in the body is located in the hypothalamus of the brain During an infection(influenza) process, the presence of microorganisms cause pyrogens(a chemical circulating in the blood that causes a rise in body temperature) to be secreted, which raise the set point of the hypothalamic thermostat Blood vessels constrict causing you to be cold, white blood cells increase to fight the infection, chills and shivering begin until the process is reversed, once this occurs the hypothalamus thermostat is reset The extent of the infection determines the amount of the fever A mild infection may cause the temperature to rise to 100.0 F
A moderate infection 102.0 F Dangerous 104.0 F Fatal over 106.0 F Oral Temperature Oral temperature requires contact with mucus membranes, so a thermometer must be disposable or requires a barrier cover This must be placed sublingually(under the tongue) into the heat pocket Anything hot or cold by mouth may alter measurement. Wait for at least 15 minutes prior to measuring
Maintain the thermometer in place for the required period of time Rectal Temperature Rectal measurement is appropriate with babies(3mo and under) Use the rectal(red) probe Use a probe cover The probe is inserted inch into the rectum(use lubrication) Steady the infants legs and ankles Be prepared for the procedure to initiate urination
or expelling of stool Axillary Temperature This is done by placing the thermometer in the axilla(armpit) This method is the least accurate Apply a probe cover, and insert the tip well into the axillary space with the probe extending down and slightly forward along the patient side Lower that patients arm over the probe Hold the probe in this position to maintain good contact
Tympanic(Aural) Membrane Thermometer The thermometer operates by the principle of measuring the strength of the infracted heat waves generated by the tympanic membrane (hypothalamus) You position the cover plastic tip properly inside the auditory canal and press the scan button, an infrared beam measures the heat waves Temporal Thermometers
This measures the temperature of the skin over the temporal artery of the forehead You place the cover plastic tip properly, press the scan button Scan the forehead keeping the probe on the skin, press and hold the scan button while slowly sliding the thermometer across the forehead until reaching the hairline If perspiration(makeup) is present, continue to hold the button, lift probe from forehead, and position on the neck behind the earlobe This is closely related to the true internal body temperature
Pulse Each time the heart beats, blood is forced into the aorta, temporarily expanding its walls and initiating a wavelike effect This effect can be palpated(felt) in the arteries that are close to the body surface and that lie over bone or firm structure The pulse can be felt in several locations on the body(659) The radial pulse(ideal) is on the thumb side of the inner surface of the wrist, lying over the radius bone
Pulse The average adult pulse rate 72 beats per minute Pulse rate is directly related to age, the younger the person, the faster the heartbeat Age Pulse rate Less than 1 year 100-170 2-6 years 90-115 6-10 years 80-110
11-16 years 70-95 Midlife adult 65-80 Older adult 50-65 Page 659 Measuring the Radial Pulse The patient should be completely relaxed and sitting comfortably or lying down Never use your thumb to measure pulse rate; there is a chance you
may feel and record your own heart rate in your thumbs artery Too much pressure may shut off circulation Too little pressure will not compress the artery sufficiently Applying the correct amount of pressure will take some practice and then become routine Check your watch, begin counting when the second hand is at 3,6,9, or 12(this makes 30 seconds easier to observe) Count the pulse for 30 seconds and multiply be 2 Measuring the Apical Pulse In some instances the radial pulse may not be appropriate to measure, it will be necessary to
listen to the heart at its apex with a stethoscope Measuring the Apical Pulse The apical pulse is counted for a full minute The bottom or lower edge of the heart is known as the apex This is the point of maximum impulse of the heart against the chest wall It can be palpitated at the left fifth intercostal space inline with the middle if the left clavicle
Measuring the Apical Pulse Apical pulse is indicated for infants and small children because of their normally rapid heart rate, which is easier to hear and count Patients with heart conditions, will require apical measurements for greater accuracy Apical pulse is always indicated if you have difficulty feeling a radial pulse and believe you may be missing beats Respiration Respiration is the combination of total
inspiration(breathing in) and the total expiration(breathing out) or inhale and exhale It is important that the patient not be aware that this being done(they can alter their rate) To accomplish this, it is common practice to observe and measure respiration rate immediately after the pulse rate, while maintaining your fingers on the radial pulse, using this method, the patient assumes you are still measuring pulse rate Respirations The normal respiration rate for adults is 16 to 20 times
per minute Newborns: range 30 to 80 Early childhood: range 20 to 40 Late childhood: 16 to 20 Abnormally slow respiration rate is known as bradypnea Abnormally fast respiration rate is known as tachypnea Excessively fast and deep breathing is known as hyperventilation Blood Pressure Learning to assess blood pressure accurately requires attention to details,
careful listening, and correct technique The term blood pressure means the fluctuating pressure that the blood exerts against the arterial walls as the heart alternately contracts and relaxes Blood Pressure Phases The phases of blood pressure are identical to those of the pulse A contraction phase, known as systole, corresponds to the beat phase of the heart and is the period of greater pressure
The relaxation phase, known as diastole, corresponds to the resting or filling action of the heart and is the period of least pressure Normal Blood Pressure Blood pressure is measured using a stethoscope and a sphygmomanometer(safigmom-a-nom-meter) Blood Pressure Readings An adult should have a systolic pressure less than 120 and a diastolic pressure less than 80 Above 140/90 indicates stage 1 hypertension
Above 160/100 indicates stage 2 hypertension Page 667 Measure Blood Pressure Place the patient in a relaxed and comfortable sitting or lying position Expose the patients upper arm well above the elbow(bare arm) Support the arm, slightly flexed Place cuff over the brachial artery, with the bottom edge of the cuff 1 to 2 inches above the elbow Apply the stethoscope at the antecubital space With one hand, close the valve on the bulb, turning clockwise Observing the manometer, rapidly inflate the cuff to about 160 mm
Open the valve, slowly releasing the air until the pulse is detected Observe the dial reading The very first pulse heard is the systolic reading The very last pulse heard is the diastolic After the reading deflate the cuff rapidly and empty the air Record you reading(chart) Cuff Size The cuff size is important in measuring a patients pressure
Hypertension Hypertension(above normal blood pressure) can result from things such as stress, obesity, high salt intake, and aging Physical conditions may include kidney disease, thyroid dysfunction, neurological disorders and vascular conditions, which make circulation more difficult, therefore requiring a greater pressure to circulate blood Hypotension A blood pressure consistently below 90/69 indicates
hypotension(below normal blood pressure) This may be normal for some people This may be present with heart failure, severe burns, dehydration, deep depression, or shock A drop in blood pressure may occur when a patient changes from sitting to standing position This is known as orthostatic hypotension Typically, if the blood pressure is measured, it will show a drop of at least 20 mm systolic and 10 mm diastolic You may need to perform orthostatic pressure on patients
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