Clinical Procedures: Chapter 34 & 35

Closed ended questions

yes or no questions

Infectious disease process: Convalescent

symptoms gone, regain in strength. Original state.

Infectious disease process: Declining

symptoms start to subside. Health returns to normal

Open ended questions.

"Describe your pain" This allows more detailed information to be documented.

Sterilization

destroys all forms of living organisms

how does the autoclave works and at what temperature

A part of sterilization. Excerts 15-30lbs of steam pressure per square inch at 250'F to 270'F/121'C to 132'C. Use precaution when autoclaving is done to avoid steam burn. Packages need to be cooled and dried before handling.

Infectious agents (pathogens): Rickettsiae

Aka obligate parasites because they depend completely on their host for survival

Drug allergies and its documentation

Allergies are coded with red ink or bright separate labels titled "Allergies" attached to chart. NKDA- if patient says they don't have any then it is labeled no known drug allergies on the chart.

Geneogram

Another type of history that consist of at least the past 3 generations of a patient to provide info to the provider so that they can determine patient's chances of developing a disease with its genetic tendencies.

Economic entity assumption

Any organization or society that is business, government agency, municipality, school district, or church

hand washing steps

Assemble equipment Remove jewelry Use a paper towel to turn faucet and adjust water temperature to lukewarm Discard paper towel Wet hands and apply soap. Use friction and work into lather, being sure to cover all parts of the hands, including wrist Rinse well, hands pointed down, be sure not to touch the insided of the sink If the first hand cleansing of the day, use nail stick or nail brush on the nails and cuticles and repeat steps 5 and 6 Use paper towels to dry hands with a blotting method from hands to elbows, discarding each towel after one use Turn faucet off with clean paper towel and discard the towel Apply lotion

Biases

Biases: how we view others based on beliefs and behaviors. Regardless of this, all patients must be respected.

Corporation

Business organized under state law

Proprietorship

Business owned by a person. The owners net worth or equity. Small business

Partnership

Business owned by two or more persons associated as partners. Loanable debts of partnership

Liabilities

Claims people to which money is owed

Clarification

Clarify any questions between you or patient to help understand.

Strep throat

Direct contact 1-3 days Fever, red and sore throat, pus spots back of throat, tender glands of neck antibiotics

Rubella (german measles)

Direct contact by droplets 12-23 days Rash, fever 2-3 days, enlarged lymph nodes, arthralgia No treatment

Pertussis (whooping cough/ bordetella)

Direct contact from respiratory mucous membranes 7-10 days Sneezing, runny nose, low fever, mild cough. After 2 weeks mucus is thick and whooping sound occurs (high pitch) Antibiotics- azithromycin, erythromycin

Review of Systems

Done when MA's job is almost over and everything is recorded on chart/form for the provider. This is called a baseline. If specimens are needed, provider might want to meet with patient first, if not then MA performs exam. Before leaving patient, thank them for their cooperation, ask if they have any other questions. Then provider comes in to do their part.

In conducting an interview know the factors that influence a screening.

Ensure privacy Be aware of your biases Establish a non-threatening, relaxed atmosphere Be aware of your own nonverbal messages Be sure the patient understands Allow the patient to do most of the talking Listen attentively to what the patient says Nonverbal communication

CDC recommendation for exposure to blood

Exposure Control Plan: Engineering Work place PPE HepB vaccination Postexposure follow up Labels/signs to communicate biohazards info/training Documented employee medical and training records.

Family History

Forewarns and prevents future family conditions. Providers who treat famillial disorders and diseases may also use genogram (another type of history).

Pinworms (enterobius vermicularis)

In/Direct transfer of eggs from anus to mouth 3 weeks-3 months Anal itching, insomnia, irritability Anthelminitics, hygeine

Infectious agents (pathogens): Bacteria

Microorganisms that vary in their morphology

Accounts payable

Money borrowed on credit

Note payable

Money borrowed to purchase major assets

Guideline for disease prevention and safety

OSHA: PPE, Biohazard/dispose, exposure control plan (updated annually to help prevent disease, trainings, laundry service cleaning (biohazard bin), hand washing, autoclaving.

Screening

Obtaining info from patients to determine who is most beneficial to handle their needs (incoming phone calls and in-person screening). Example: Professionalism ( privacy, aware of biases, relaxed atmosphere, body language, patient understandment, patients talks most, listening)

Monetary unit assumption

One of two main assumptions in GAAP, requiring transaction data in terms of money

Infectious agents (pathogens): Parasites

Parasites are organisms that depend on another living organism for nourishment. In humans they are called protozoa.

Social/Occupational History

Personal/lifestyle habits that may cause diseases/conditions. If patient "hides" info their provider may ask them later with educational materials. Addiction, work related, hobbies, diets, exercise.

Scope of Practice

Principles of self boundaries of the profession

reflection questions.

Reflect on patients concerns (care and listen to what they're saying).

Assets

Resources owned by a business

restatement question

Restate concern (if patient seems to misunderstand question repeat or restate the question).

Sanitization

Scrubbing to remove materials such as body tissue, blood, body fluids.

Infectious disease process: Incubation

Silent stage. Pathogen gains entry. First signs of symptoms appear.

Infectious agents (pathogens): Fungi

Simple parasitic plants that depend on other life forms for a nutritional source

Infectious agents (pathogens): Viruses

Smallest of the microorganisms, may be viewed only by an electron microscope

SOAP and the difference between Subjective, Objective, Assessment and Plan.

Subjective (patients description of how they feel/symptoms) Objective (professional findings- vitals, examinations, swelling, bruising,etc) Assessment (made by the provider upon examination) Plan (what course of action will be taken)

Stockholders' equity

The ownership claim on total assets

Retained earnings

The section of the balance sheet is determined by three items: revenues, expenses, and dividends

Cost

The value exchanged at the time something is required

Paid in Capital

Total amount paid in stockholders

Prioritizing

Triage (trauma and disaster situations that are assessed and sorted). Arranged in order of importance.

Market value

Value determined by market for buildings/property at the time of sale

Chief complaint and its descriptive information (subjective and objective: short written)

What brings patient in (write down in patients own words). In descriptive info write down patients own words of describing their reason.

Infectious disease process: Acute

disease reaches highest point. Where you diagnose disease

Disinfection

disease-producing microorganisms/pathogens are killed. Spores aren't always killed.

Infectious disease process: Prodrominal

first onset of signs and symptoms occur

Clinical Diagnoses

identification of disease by history, laboratory findings, and symptoms

Scarlet fever (scarlatina streptococcal)

in/direct contact 1-7 days Fever, red and sore throat, pus spots back of throat, tender glands of neck, strawberry tongue, rash on skin and in mouth, nausea, vomitting Rest and antibiotics

Pneumonia

in/direct contact Abrupt onset High fever, shaking, chills, cough Antibiotics, liquids, rest

Mumps

in/direct contact of droplets from nose/throat 12-25 days Fever, headache, muscle aches, tiredness, no appetite, swollen salivary glands under ear(s) Wait it out

Scabies

in/direct contact with infested clothing/bedding 2-6 weeks Intense itching, raw skin, lined shaped scabicide

VRE (vancomycin resistant enterococci)

in/direct contact with surfaces and people 24 hours Red and tender skin, UTI symptoms, back pain, diarrhea, fever, chills

Present illness

present or past illness. Contains chief complaint, when problem started, what patient has done for the condition, if treatment was attempted (effective or not).

Over-the-counter

referring to accessible, nonprescription drugs.