Transcript Chapter 13 - Horizon Medical Institute

CHAPTER
13
Beginning the Patient’s
Record
UNIT
1
In-Person Screening
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The Origin of Triage
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Triage comes from the French word that
means “to sort.”
This refers to the process medics used
during war time to sort out the wounded
so that the most seriously wounded were
treated first.
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The Purpose of Screening
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Screening is the process of obtaining
information from the patient to determine
his or her medical condition.
Screening can be done in person or over
the phone.
This helps the patient focus on the main
concern.
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Categories Used for
Determining Urgency
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Difficulty breathing comes first.
Chest pain
Severe bleeding
Head injury
Open wounds
Burns
Fractures
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In-Person Screening

Goals

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Determine why the patient is seeking health
care.
Discover what the patient sees as the main
problem (chief complaint).
Find out any other patient concerns.
Learn what, if anything, the patient has done
about the problem.
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Factors Influencing Screening
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Ensure privacy.
Be aware of your biases.
Establish a nonthreatening, relaxed
atmosphere.
Be aware of your nonverbal messages,
as well as the patient’s.
Be sure the patient understands.
(continued)
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Factors Influencing Screening

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Allow the patient to do most of the
talking.
Listen to what the patient says.
Use open-ended questions.
Focus on the interview.
Conclude with a summary.
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Unit Summary



What is the purpose of triage?
What is the meaning of screening?
What symptom would come first when
determining urgency?
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UNIT
2
The Medical History
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Information Requested on
the Health History Form
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Medications
Allergies
Symptoms
Medical history
Hospitalizations
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Occupational
concerns
Health habits
Pregnancy history
Serious illnesses
Family history
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The Purpose of Obtaining
a Health History

The health history forms the basis for the
physician to understand the present
health status of the patient by evaluating:
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The patient’s past medical history
The present history of the illness
Childhood diseases
Family history
Patient’s personal habits
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The Purpose of a Genogram

Genograms help the patient identify
familial disorders for the physician.
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Unit Summary


What are the 10 categories of
information requested in the health
history form in this unit?
What is the purpose of a genogram?
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UNIT
3
Body Measurements
and Vital Signs
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The Importance of Measuring a Patient’s
Height and Weight

The initial measurement of height and
weight acts as a baseline and allows the
physician to monitor proper growth and
development or to monitor disease
progression.
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Balance Beam Scale
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Cardinal Signs

Identify four vital indictors of body
functions that are essential to life
1.
2.
3.
4.
Temperature
Pulse
Respirations
Blood pressure
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Four Vital Signs and
What They Measure
1.
Temperature

2.
Pulse

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Measures the ability of the body to control
heat
Measures the rate, volume, and rhythm of
the heart
(continued)
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Four Vital Signs and
What They Measure
3.
Respirations

4.
Measures the rate and quality of breathing
Blood pressure

Measures the force of the heart and the
condition of the blood vessels
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How the Body Controls Temperature
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The balance between heat production
and heat loss determines the body’s
temperature.
The body produces heat by changing
food into energy and through physical
activity.
The body loses heat through breathing
and elimination of body waste.
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Contraindications to Taking
Oral Temperatures
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Infants and children under age 6
Respiratory complications
Oral injuries
Confusion or disorientation noted in the
patient
Recent oral surgery
Facial paralysis
Nasal obstruction
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Average Normal Temperatures and
Accuracy of Measurements
Average
Oral
Axillary
Rectal
98.6°F
(37°C)
97.6°F
(36.5°C)
99.6°F
(37.5°C)
97.6–99.6 °F 96.6–98.6 °F 98.6–100.6
Normal
°F
(36–37°C)
Temperature (36.5–37.5
°C)
(37–38.1°C)
Range
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Ways to Take Temperatures
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Oral
Aural
Axillary
Rectal
Temporal artery
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The Pulse

The pulse
measures the
force of the blood
that is exerted on
the walls of the
arteries as the
heart contracts
and relaxes.
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Pulse Points
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Carotid: the neck, on the side of the
trachea
Brachial: the inner surface of the elbow
Radial: the thumb side of the wrist
Femoral: midway in the groin
Popliteal: at the back of the knee
Dorsalis pedis: the instep of the foot
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Normal Pulse Rates
Age
Less than 1 year
Pulse Rate
100–170
2–6 years
90–115
6–10 years
80–110
11–16 years
70–95
Midlife adult
65–80
Aged adult
50–65
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Factors That Affect Pulse Rate
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Exercise or activity
Age
Gender
Physical condition
Condition of the nervous system
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Two Additional Pulse Characteristics
1.
Volume

2.
The force or strength of the pulse
Rhythm

The regularity or equal spacing of the pulse
beats
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Indicators for Apical Pulse
Measurements
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Infants and small children
Patients with heart conditions
Difficulty feeling the pulse
Excessively rapid or slow pulse beat
Pulse deficit
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Pulse Deficit

A pulse deficit is when the patient has a
higher apical than radial pulse rate
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Take both apical and radial pulse rate
measurements.
Subtract the radial result from the apical.
The difference is identified as the pulse
deficit.
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Normal Respiration

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One respiration is the combination of
total inspiration (breathing in) and total
expiration (breathing out).
Other frequently used terms


Inhalation (breathing in)
Exhalation (breathing out)
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Four Abnormal Breathing Patterns
1.
Hyperventilation

2.
Dyspnea
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3.
Difficult or labored breathing
Apnea

4.
Abnormally fast and deep breathing
Absence of breathing
Rales

Noisy breathing
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Cheyne-Stokes

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This represents periods of slow, shallow
breathing that increase in depth and
frequency and are followed by a 10–20
second period of apnea.
This pattern frequently precedes death.
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Blood Pressure

Measuring blood pressure requires
attention to details, careful listening, and
correct technique.
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Circulatory Factors Reflected by Blood
Pressure Measurement

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The amount of blood being pumped
The force with which the blood is being
pumped
The size of the arteries by measuring
both constriction and dilation phases
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How the Body Maintains
Blood Pressure
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The heart exerts pressure on the blood
The brain controls the rate of the
heartbeat and the size of the arteries
through the autonomic nervous system.
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The Phases of Blood Pressure

Contraction phase
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Known as systole
This represents the period of greatest
pressure.
Relaxation phase

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Known as diastole
This represent the period of least pressure.
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Unit Summary



What are the four vital signs?
What does each vital sign measure?
Why is weight an important
measurement in the medical office?
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Keys to Career Success

The successful medical assistant assists
the physician by understanding the
importance of accuracy and
completeness when screening the
patient and taking vital sign
measurements.
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Hot Links to Career Success

www.lifeclinic.com

Life Clinic Health Management Systems
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