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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5519_Библиотеки_им_академика_М_И_Перельмана.pdf
Chapter 16 Medical History and Patient Assessment 331
Procedure 16-8 Measuring the Radial Pulse
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1. Wash your hands rst. Have a watch or clock with
a second hand available.
2. Greet the patient by name if you have not already
done so and explain the procedure. In most cases, the
pulse is taken at the same time as other vital signs.
3. Position the patient so the arm is relaxed. The arm
should be supported either on the patient’s lap or
on a table. If the arm is not supported, or the patient
is uncomfortable, it may be hard to nd the pulse.
4. Use the index, middle, and ring ngers of your dominant hand to nd the radial pulse. The pulse point
is located on the patient’s thumb side of the wrist.
Do not use your own thumb—it has a pulse of its
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own that can be confused with the patient’s pulse.
You may place your thumb on the opposite side
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of the patient’s wrist to steady your hand.
5. Press your ngers on the pulse point. Press rmly
enough to feel the pulse. Pressing too rmly can
cause the pulse to disappear.
If the pulse is regular, count it for 30 seconds,
r
watching the second hand of your watch.
Multiply the number of pulsations by 2 since the
pulse is always recorded as the number of beats
per minute.
If the pulse is irregular, count it for a full
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60 seconds. Otherwise, the measurement may be
inaccurate.
6. Record the pulse rate in the patient’s medical record
with the other vital signs. Make a note and notify
the doctor if the rhythm is irregular and the volume
is thready or bounding.
Procedure 16-9 Measuring Respirations
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1. Wash your hands. Have a watch or clock with a
second hand available.
2. Greet the patient by name if you have not already.
3. Observe carefully for the easiest area to assess
respirations. Some patients have abdominal
movement instead of chest movement during
respirations.
4. In most cases, respirations are measured at the same
time as the pulse. After counting the radial pulse,
continue to watch the second hand of your watch.
Begin counting respirations. Count a complete rise
and fall of the patient’s chest as one respiration.
It is best not to inform the patient that you are
r
counting respirations. A patient who is aware
that you are counting respirations may alter his
breathing pattern.
(Reprinted from Kronenberger J, Ledbetter J.
Lippincott Williams & Wilkins’ Comprehensive
Medical Assisting. 5thed. Philadelphia, PA: Wolters
Kluwer; 2016.)
5. If the breathing pattern is regular, count the respiratory rate for 30 seconds. Then, multiply by 2. If
the pattern is irregular, count for a full 60 seconds.
Otherwise, the measurement may be inaccurate.
6. Record the respiratory rate in the patient’s medical
record along with the other vital signs. Also, note
the rhythm if irregular. Mark down any unusual
sounds, such as wheezing.
332 Section IV Clinical Medical Assistant Skills
Procedure 16-10 Measuring Blood Pressure
1. Wash your hands and gather a sphygmomanometer
and a stethoscope.
2. Greet the patient by name and explain the
procedure.
3. Position the patient with the arm to be used
supported with the forearm on the lap or a table.
The arm should be slightly exed, with the palm
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upward. This makes it easier to nd and palpate
the brachial artery.
The upper arm should be level with the patient’s
r
heart. If the upper arm is higher or lower than
the heart, the reading may be inaccurate.
(Reprinted from Kronenberger J, Ledbetter J. Lippincott
Williams & Wilkins’ Comprehensive Medical Assisting.
5thed. Philadelphia, PA: Wolters Kluwer; 2016.)
7. Hold the air pump in your dominant hand, with
the valve between your thumb and forenger. Turn
the valve screw clockwise to tighten it. The cuff will
not inate with the valve open.
Be careful not to make the valve screw so tight
r
that it’s hard to release. You need to be able to
loosen it with one hand after the cuff is inated.
P
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Y
(Reprinted from Kronenberger J, Ledbetter J.
Lippincott Williams & Wilkins’ Comprehensive
Medical Assisting. 5th ed. Philadelphia, PA: Wolters
Kluwer; 2016.)
4. Expose the patient’s arm. Clothing over the area
can block out the sounds you will need to hear. If
the sleeve is pulled up, ensure it is not tight. A sleeve
that is too tight can act as a tourniquet, decreasing
the ow of blood and causing an inaccurate blood
pressure reading. Make sure the patient’s legs are
not crossed and ask the patient to not talk during
the procedure.
5. Palpate the brachial pulse in the antecubital area—
the region of the arm in front of the elbow.
Center the deated cuff directly over the brachial
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artery.
The lower edge of the cuff should be 1 to 2 inches
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above the antecubital area.
If the cuff is too low, it may interfere with place-
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ment of the stethoscope and cause noises that
obscure the Korotkoff sounds.
6. Wrap the cuff smoothly and snugly around the
arm. Secure the cuff with the Velcro edges.
(Reprinted from Kronenberger J, Ledbetter J. Lippincott
Williams & Wilkins’ Comprehensive Medical Assisting.
5thed. Philadelphia, PA: Wolters Kluwer; 2016.)
8. First, determine a reference point for how far you
need to inate the cuff.
While palpating the brachial pulse with your
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nondominant hand, inate the cuff.
Note the point or number on the dial or glass
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tube column at which you no longer feel the
brachial pulse.
This will give you a reference point for reinat-
r
ing the cuff when taking the blood pressure.
9. Deate the cuff by turning the valve counterclockwise. Wait at least 30 seconds before reinating the
cuff. The waiting time allows blood circulation to
return to the extremity.
10. Clean the earpieces of the stethoscope with an alcohol wipe. Place the stethoscope earpieces in your
ears with the openings pointed slightly forward.
Stand about 18 inches from the manometer with
the gauge at eye level to reduce the chances of making an error while taking the reading.
Chapter 16 Medical History and Patient Assessment 333
Procedure 16-10 Measuring Blood Pressure (continued )
11. Place the diaphragm of the stethoscope against the
brachial artery and hold it in place with your nondominant hand. Don’t press too hard or you may
obliterate the pulse. On the other hand, if you do not
press rmly enough, you may not hear the sounds.
The stethoscope tubing should hang freely with-
r
out touching or rubbing any part of the cuff. If
the stethoscope rubs or touches any other objects,
environmental sounds may make the Korotkoff
sounds impossible to hear.
13. Once the cuff is inated appropriately, turn the
valve counterclockwise. You want to release the air
at about 2 to 4 mm Hg/sec.
Releasing the air too fast will cause missed beats.
r
Releasing it too slowly will interfere with
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circulation.
14. Listen carefully while watching the gauge. Aneroid
and mercury-free measurements are always made
as even numbers, because of the way the manometer is calibrated.
Note the point on the gauge at which you hear
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the rst clear tapping sound. This is the systolic
sound or Korotkoff phase 1.
15. Continue to listen and deate the cuff. When you
hear the last sound, note the reading, and quickly
deate the cuff.
The last sound heard is the Korotkoff phase
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5sound. It is recorded as the diastolic pressure
or the bottom number.
If you are unsure of the reading, wait 1 to
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2 minutes before repeating the procedure. Never
immediately reinate the cuff.
(Reprinted from Kronenberger J, Ledbetter J.
Lippincott Williams & Wilkins’ Comprehensive
Medical Assisting. 5th ed. Philadelphia, PA: Wolters
Kluwer; 2016.)
12. With your dominant hand, turn the screw near the
bulb just enough to close the valve. Inate the cuff.
Pump the valve bulb to about 30 mm Hg above
r
the number you noted during step 8.
Inating more than 30 mm Hg above the base-
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line is uncomfortable for the patient and unnecessary. But if you don’t inate the cuff enough,
the systolic reading may be inaccurate.
(Reprinted from Kronenberger J, Ledbetter J.
Lippincott Williams & Wilkins’ Comprehensive
Medical Assisting. 5th ed. Philadelphia, PA: Wolters
Kluwer; 2016.)
16. Remove the stethoscope earpieces from your ears.
Remove the cuff and press any remaining air from
the bladder of the cuff.
If this is the rst reading or a new patient, the
r
physician may also want a reading in the other
arm or in another position.
In some patients, blood pressure varies between
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the arms or in different positions such as lying
or standing.
17. When all readings are nished, put the equipment
away and wash your hands.
18. Record the reading. The systolic pressure is always
written as a fraction over the diastolic pressure
(e.g., 120/80). Note which arm was used—RA for
right arm, or LA for left arm. Record the patient’s
position if other than sitting.
334 Section IV Clinical Medical Assistant Skills
Preparing for Externship
One of the tasks that medical assistants do in the One
of the tasks that medical assistants do in the ofce
is to collect the medical history of patients. This
includes interviewing new patients and updating
information for established patients. As an extern,
you will observe the techniques used by the ofce
staff to gather this information for the patient record.
Take note of how the questions are stated and the
way the patient responses are input into the medical
record. Remember the externship experience is the
“real world” and the scenarios you practiced in class
Chapter Recap
● Medical assistants may need to collect information for
the patient’s medical history and medical assessment. The
role of the medical assistant in collecting information
depends on the policies of the medical ofce.
● The medical history provides the physician with a
basis for asking questions during an examination. It
also helps the physician understand how the patient’s
illness and lifestyle interact.
● During an assessment, patients are interviewed to
establish signs and symptoms of illness. For each visit,
a chief complaint and present illness are documented
in the patient’s record.
● Physical measurements also provide information
about a patient’s health. Medical assistants may collect
anthropometric measurements and measure vital signs.
● Anthropometric measurements for adults typically
include height and weight. Pediatric measurements
may also include head and chest circumference.
● Body temperature reects the balance between
heat produced and heat lost by the body. The type
are now playing out. What you hear from the patient,
you must accurately document in the record for the
physician or provider to read. Watch for spelling and
grammar errors. You will become familiar with common phrases and ways to express what the patient
says. You may want to review other entries made
into the record on previous visits. This will help you
to become familiar with proper charting styles. It
will also allow you to see the level of detail necessary for proper and adequate documentation of the
patient’s visit.
of thermometer used for measuring temperature
depends on the practices of the medical ofce.
● Four different methods for taking temperature are
oral, rectal, axillary, and tympanic. The method must
be documented in the patient’s medical record, along
with the reading.
● Pulse and respiration rates are often measured at the
same time. Three important characteristics of the
pulse are the rate, rhythm, and volume. Important
characteristics of respirations are the rate, rhythm,
and depth.
● Blood pressure is measured during two phases of
the cardiac cycle called systole and diastole. Five
phases of Korotkoff sounds can be identied with a
stethoscope. The systolic pressure reading is measured
during phase 1. The diastolic pressure reading occurs
during phase 5.
● Measuring blood pressure can be tricky. By being
aware of possible sources of errors, medical assistants
can make sure their readings are accurate.
Online Resources for Students
Resources for students available on thepoint.
lww.com include the following:
● Audio Glossary
● Animations
● Competency Evaluation Forms
● Harris CareTracker Case Studies
● Interactive Games & Activities
● Certication Preparation Question Bank
● Videos
Chapter 16 Medical History and Patient Assessment 335
Exercises and Activities
Certication Preparation Questions
1. Which of the following is part of the social history
information on a new patient medical history
form?
a. Age
b. Date of birth
c. Prior surgical procedures
d. Alcohol consumption
e. Occupation
2. Which of the following supplies is required for
obtaining a temperature on an infant?
a. Tympanic thermometer
b. Sterile exam gloves
c. Digital thermometer with blue tip
d. Biohazard sharps container
e. Glass thermometer with red tip
3. Which of the following is an accurately recorded
high blood pressure reading?
a. 220/70 bpm
b. 160/70 mm
c. S190/D80
d. 150/95
e. 100/220
4. Which of these is the best response from the
medical assistant if a patient refuses to provide
information to complete the medical history form?
a. I will need to obtain this information or the
doctor will not be able to treat you today.
b. We will reschedule your appointment until you
can provide the needed information.
c. I know this is difcult; however, the physician
will need to have the information before he will
see you.
d. I will make a note on this form that you are
refusing to provide any information.
e. I will inform the physician that you are unable
to provide the needed information.
5. What is the best location to obtain a radial pulse?
a. Wrist on the little nger side
b. Antecubital area of the arm
c. Upper arm 2 inches above the elbow
d. Wrist on the thumb side
e. Midarm between the elbow and the hand
6. Which of the following is the rst step in
obtaining a blood pressure?
a. Apply the blood pressure cuff.
b. Pump the bulb on the gauge to ensure that it
works.
c. Check the size of the cuff to ensure it is
appropriate for the patient.
d. Locate the brachial artery and place the
stethoscope over it.
e. Determine the pulse pressure.
7. Which of these is a factor that a patient can
change to affect their blood pressure?
a. Age
b. Gender
c. Weight
d. Family history
e. Culture
8. Which of the following represents the blood
pressure reading if the pulse pressure is 40?
a. 110/60
b. 122/82
c. 130/94
d. 160/100
e. 90/58
9. If a patient’s height registers 69 inches on the
height meter, how tall is the patient?
a. 6 feet 0 inches
b. 5 feet 11 inches
c. 5 feet 9 inches
d. 5 feet 7 inches
e. 4 feet 9 inches
10. Which of the following is not considered a sign?
a. Coughing
b. Rash
c. Bleeding
d. Headache
e. Bruise
336 Section IV Clinical Medical Assistant Skills
P
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r
valuable and sensitive data on the planet. It is often
costly to obtain, essential in diagnosing and treating life-threatening diseases, and extremely personal.
Collecting, documenting, managing, and protecting
this information, therefore, are weighty responsibilities of the medical assistant. Fortunately for you, electronic health record systems, such as CareTracker, have
revolutionized the documentation and management of
patient data, making it possible to capture and organize
a vast amount of complex data and make it accessible
to health care professionals around the world while protecting the patient’s privacy.
in CareTracker include the following:
r
CareTracker Connection
Documenting Patient Health
History and Assessment Findings
CareTracker Activities Related to This Chapter
Case Study 4: Charting Patient Information
A patient’s health information is some of the most
Tasks discussed in this chapter that can be performed
Documenting the following patient health
information:
Chief complaint
Present illness
Vital signs
Heart rate
Respiratory rate
Blood pressure
Temperature
Anthropometric measurements
Height
Weight
Allergies
Medications
Immunizations
Medical history
Diseases and conditions
Injuries
Hospitalizations
Surgeries
Social history
Diet
Exercise
Tobacco use
Alcohol use
Sexual and reproductive history
Family history
Many of these tasks are discussed in CareTracker
Connection features in other chapters. A task we’ll consider here is entering a patient’s vital signs.
Some of the rst data you will obtain during a
patient visit are vital signs. In CareTracker, these data
are entered into the Medical Record module, in the Vital
Signs application.
Chapter 16 Medical History and Patient Assessment 337
Within this application, clicking on the
button causes the Vital Signs window to appear,
where you may enter the patient’s vital signs and chief
complaint. Note that any measurements that are outside
of normal parameters are automatically highlighted
after the data are entered, such as the body mass index,
shown in the gure below.
Once you save this information, a summary of the
vital signs appears on the main Vital Signs screen. Again,
abnormal measurements are highlighted.
338 Section IV Clinical Medical Assistant Skills
These data are now available throughout the
CareTracker system and may appear in other applications, such as the Progress Note. You’ll get a chance
to practice this task in Case Study 4: Charting Patient
Information.
To access Case Study 4, go to http://thepoint.lww.
com, log in using your username and password, search
for The Complete Medical Assistant, click on “Student
Resources,” nd the Harris CareTracker materials, and
click on “Case Study 4.”
P
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1. Visit the American Heart Association Web site for
2. Go to Web site for the Centers for Medicare and
Internet Activities
information regarding blood pressure recommendations and how to manage hypertension.
Medicaid Services (www.CMS.gov). Locate the site
with information regarding HIPAA and the Medical
Privacy of Protected Health Information.
Assisting with the Physical
17
Examination
Chapter Objectives
● Identify the medical assistant’s role in assisting with
the physical examination.
● List the equipment and supplies needed in the
patient examination room.
● Prepare and maintain patient examination and
treatment areas.
● Explain the care and use of the equipment and
instruments used in a physical examination.
● Describe six examination techniques used during the
physical examination.
● Prepare patients for and assist with routine and
specialty examinations.
● Describe the basic examination positions and
explain their use.
● Understand the sequential process used by the
physician to complete a physical examination.
● Explain how the physician evaluates a patient’s
posture, gait, and reexes.
● Instruct patients how to recognize cancer warning
signs and perform self-examinations of the breasts
and testicles.
● List the guidelines for annual examinations,
immunizations, and cancer screening.
CAAHEP & ABHES Competencies
CAAHEP
● Assist physician with patient care.
● Apply critical thinking skills in performing patient
assessment and care.
● Use language/verbal skills that enable patients’
understanding.
● Demonstrate respect for diversity in approaching
patients and families.
● Explain the rationale for performance of a
procedure to the patient.
● Document patient care.
● Respond to nonverbal communication.
ABHES
● General/physical examination
● Specialty examination
● Working with diverse populations
339
340 Section IV Clinical Medical Assistant Skills
Chapter Terms
Accommodation
Asymmetry
Auscultation
Gait
Inspection
Manipulation
Mensuration
Ophthalmoscope
Abbreviations
CC
CPX
ECG
Case Study
Medical assistant, Karen Stuart, escorts female
patient, Rebecca Martin, to an examination room
where she is scheduled for a complete physical
examination. The patient tells Karen that it has
been several years since she has had physical
examination. The patient also shares with Karen
that her mother died recently and she has had a
PERRLA
PAP
PH
Otorhinolaryngologist
Otoscope
Palpation
Percussion
PI
ROM
very difcult time coping with the death of her
mother. She decided to come to the ofce for a complete physical examination because she has been
feeling very tired and depressed since the death of
her mother. The patient states that she is afraid the
physician may discover something that might be
very serious or even terminal.
Speculum
Stethoscope
Symmetry
ROS
Study Skill
Students often overlook the value of the chapter
objectives. After you have completed reading and
studying the information in this chapter, write down
each chapter objective. Give an answer or explanation for each objective based on the material included
in the chapter. For example, the last objective states
“List the guidelines for annual examination, immunization, and cancer screening.” Write a list for each
of these. This can be used as a review and study tool
prior your course exam or national certication exam.
C
O
G
The complete physical examination (CPX) is one of the
most typical services provided in the physician’s ofce.
Patients may schedule to have a complete physical
examination for various reasons including:
r
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THE BASIC PHYSICAL
EXAMINATION
Determining baseline information of a new patient
Requirement for employment, attending school, and
playing sports
Approval for health or life insurance
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Periodic assessment of existing patients
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A complete physical exam allows the physician to
assess the patient’s general state of health. Through
the process of performing the examination, the physician does a review of systems (ROS) to detect signs and
symptoms of disease. The complete physical examination process includes:
Obtaining or updating the patient’s medical history
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Performance of the actual physical examination
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Ordering laboratory tests
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Scheduling diagnostic tests
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The medical assistant duties may vary according to
the physician’s preference and the practice’s policies.
Typically, the medical assistant will be responsible for:
Preparing the examination room
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Assisting with or obtaining the patient’s medical
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history
Preparing the patient for examination
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Assisting the physician during the examination
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Collecting specimens for laboratory testing
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Performing or scheduling diagnostic tests
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Cleaning the examination room
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