General Patient Care Part 2

Learning Objectives

By the end of this chapter, you will be able to:

4.Distinguish between the types of patient examinations and the medical assistant's role in each.

5.Apply the principles of medical and surgical asepsis to prevent healthcare-associated infections.

6.Perform and document patient vital sign measurements accurately, including temperature, pulse, respiration, blood pressure, and pain.

7.Identify the correct patient positions and explain their clinical indications.

8.Recognize the steps for patient preparation for common diagnostic procedures and minor office surgery.

9.Apply safety protocols, including the CDC Standard Precautions and OSHA Bloodborne Pathogens Standard, in the ambulatory care setting.

1.1 The Patient Examination: Types and MA Roles

The clinical medical assistant (CMA) is the facilitator of the patient examination. Your primary duties include preparing the room, ensuring patient privacy, obtaining the chief complaint, and assisting the provider. You must be proficient in the three main types of examinations:

Complete Physical Examination (CPE): A head-to-toe assessment of all body systems. The patient is typically fully disrobed and wearing a gown. Your role is to ensure the room is warm, the patient is draped properly, and all equipment (e.g., ophthalmoscope, otoscope, tuning fork) is within reach.

Focused Examination: An assessment of a specific body system or complaint (e.g., a sore throat or a knee injury). The patient only undresses the affected area. You must provide appropriate draping to expose only the area being examined.

Follow-up Examination: A brief assessment to monitor a chronic condition (e.g., hypertension) or the progress of a treatment plan. This often involves measuring vital signs, weight, and asking about medication compliance.

The "Chief Complaint" is the reason for the patient's visit, stated in the patient's own words. You must record this verbatim in the patient's chart, using quotation marks (e.g., "I have a sharp pain in my right side"). Do not interpret or rephrase it.

Patient Preparation: Always verify the patient's identity using two identifiers (e.g., name and date of birth). Explain the procedure, ensure the room is clean and stocked, and provide a gown and drape. For a CPE, instruct the patient to empty their bladder before the exam begins.

1.2 Medical and Surgical Asepsis

Asepsis is the absence of pathogenic microorganisms. Understanding the difference between the two types is critical for the NHA exam.

Medical Asepsis (Clean Technique): This practice reduces the number of and prevents the spread of microorganisms. It is used in routine patient care, such as administering oral medications, taking vital signs, and handling linens. Key principles include:

Performing hand hygiene before and after patient contact.

Using clean gloves when contact with body fluids is anticipated.

Cleaning contaminated surfaces with an approved disinfectant.

Containing soiled linens and disposing of waste properly.

Keeping the floor clean; never place items directly on the floor.

Surgical Asepsis (Sterile Technique): This practice eliminates all microorganisms, including spores. It is required for any procedure that breaks the skin, enters a sterile body cavity, or involves invasive devices (e.g., inserting a Foley catheter, wound suturing, minor surgery). Key principles include:

Sterile field: A sterile barrier (e.g., a sterile drape) that is considered free of microorganisms. Only sterile items may touch the sterile field.

Sterile packaging: Check the integrity and expiration date of all sterile packages. If a package is torn, wet, or expired, it is considered contaminated.

Maintaining the sterile field: Never turn your back on a sterile field. Keep the field in your direct line of sight at all times. Do not reach across the field. The edge of a sterile drape (1-inch border) is considered non-sterile.

Gloving: When donning sterile gloves, keep your hands above your waist and below your shoulders. Interlock your fingers to avoid touching the outside of the glove with your bare skin.

1.3 Vital Signs: Measurement and Documentation

Vital signs are objective measurements of the body's basic functions. You must know the normal ranges for adults and the correct technique for measurement.

Temperature (T):

Normal Range: 97.8°F to 99.1°F (36.5°C to 37.3°C), depending on the route.

Routes:

Oral: Most common. Contraindicated for patients who are confused, have oral surgery, are on oxygen, or have a history of seizures.

Rectal: Most accurate core temperature. Used for infants and when oral is contraindicated. Insert the thermometer 1 to 1.5 inches into the rectum.

Axillary: Least accurate. Place the thermometer in the center of the armpit.

Tympanic (Ear): Measures the temperature of the tympanic membrane. Pull the ear pinna up and back for an adult, and down and back for an infant/child under 3 years.

Temporal (Forehead): Non-invasive, uses infrared scanning of the temporal artery.

Pulse (P):

Normal Range: 60 to 100 beats per minute (bpm) for a resting adult.

Sites: Radial (wrist) is most common. Other sites include carotid, brachial, femoral, popliteal, and dorsalis pedis.

Assessment: Note the rate (number of beats per minute), rhythm (regular or irregular), and volume/strength (bounding, normal, weak/thready).

Technique: Use your index and middle fingers. Do not use your thumb, as it has its own pulse. Count for 30 seconds and multiply by 2 for a regular rhythm; count for a full 60 seconds if the rhythm is irregular.

Respiration (R):

Normal Range: 12 to 20 breaths per minute for a resting adult.

Technique: Observe the rise and fall of the patient's chest. Count for 30 seconds and multiply by 2. Crucial: Do not tell the patient you are counting their respirations, as they will alter their breathing pattern. Count them immediately after taking the pulse, keeping your fingers on the wrist.

Assessment: Note the rate (bradypnea < 12, tachypnea > 20), rhythm, and depth (shallow, normal, deep).

Blood Pressure (BP):

Normal Range: Less than 120/80 mmHg.

Classification (per AHA):

Normal: < 120/80 mmHg

Elevated: 120–129 / < 80 mmHg

Hypertension Stage 1: 130–139 / 80–89 mmHg

Hypertension Stage 2: ≥ 140 / ≥ 90 mmHg

Technique:

60.The patient should be seated with feet flat on the floor, back supported, and arm supported at heart level. No caffeine or smoking for 30 minutes prior.

61.Select the correct cuff size. The bladder should encircle at least 80% of the arm circumference. A cuff that is too small will give a falsely high reading; a cuff that is too large will give a falsely low reading.

62.Palpate the brachial pulse. Place the stethoscope bell over the brachial artery.

63.Inflate the cuff to 30 mmHg above the point where the pulse disappears.

64.Deflate slowly (2–3 mmHg per second).

65.Systolic (SBP): The first audible "thump" (Korotkoff sound Phase I).

66.Diastolic (DBP): The point where the sounds disappear (Korotkoff sound Phase V).

Pain (P):

Assessment: The "5th vital sign." Use the PQRST mnemonic:

Provokes/Palliates: What makes it better or worse?

Quality: What does it feel like (sharp, dull, burning)?

Region/Radiation: Where is it, and does it spread?

Severity: Rate on a scale of 0–10.

Timing: When did it start, and is it constant or intermittent?

1.4 Patient Positions

You must know the name, description, and clinical use of each position.

Position	Description	Clinical Use
Supine	Lying flat on the back, legs extended.	General exams, abdominal assessment, CPR.
Prone	Lying flat on the abdomen, head turned to the side.	Back and spine examinations.
Fowler's	Semi-sitting position, head of bed elevated 45–60 degrees.	Breathing difficulties, post-operative recovery, nasogastric tube insertion.
Semi-Fowler's	Head of bed elevated 30–45 degrees.	Similar to Fowler's, but for patients who cannot tolerate a higher angle.
High Fowler's	Head of bed elevated 90 degrees (sitting upright).	Severe respiratory distress, feeding.
Trendelenburg	Supine, with the feet elevated higher than the head (head down).	Postural drainage, shock (historically), pelvic exams (rarely).
Reverse Trendelenburg	Supine, with the head elevated higher than the feet.	Hiatal hernia, post-operative gallbladder surgery, to reduce pressure on the head.
Lithotomy	Supine, with hips and knees flexed, feet in stirrups.	Pelvic exams, Pap smears, urinary catheterization.
Sims' (Left Lateral)	Lying on the left side, right knee and thigh drawn up toward the chest.	Rectal exams, enemas, administration of suppositories.
Knee-Chest	Kneeling, with chest resting on the table and buttocks elevated.	Rectal and proctologic exams, to reposition a retroverted uterus.

1.5 Preparation for Diagnostic Procedures and Minor Surgery

Diagnostic Procedures:

Electrocardiogram (ECG): Explain the procedure, ensure the patient is relaxed and not talking. Shave hair from electrode sites if necessary. Apply electrodes to the correct anatomical landmarks (limb leads on the wrists and ankles, precordial leads V1–V6 on the chest).

Pulmonary Function Tests (PFTs): Instruct the patient to avoid smoking, eating a heavy meal, or using bronchodilators for a specified period before the test. Demonstrate the breathing technique (maximal inspiration, forced expiration).

Specimen Collection: For a clean-catch midstream urine sample, instruct the patient to clean the urethral meatus, begin urinating, and then collect the midstream portion in the sterile cup. For a stool specimen, provide the patient with a collection kit and specific instructions on avoiding contamination with urine or toilet water.

Minor Office Surgery (e.g., suture removal, wound care, incision and drainage):

Informed Consent: The provider is responsible for obtaining informed consent. The MA's role is to witness the patient's signature and ensure the consent form is signed before the procedure begins.

Preparation: Set up a sterile field with all necessary instruments (e.g., scalpel, forceps, suture material, sterile gloves, antiseptic). Position the patient appropriately.

Post-procedure: Apply a sterile dressing. Instruct the patient on wound care, signs of infection (redness, swelling, warmth, purulent drainage, fever), and when to return for follow-up.

1.6 Safety Protocols and Infection Control

CDC Standard Precautions: These are the minimum infection prevention practices that apply to all patient care, regardless of suspected or confirmed infection status. They are based on the principle that all blood, body fluids, secretions, excretions (except sweat), non-intact skin, and mucous membranes may contain transmissible infectious agents. Key elements include:

Hand hygiene (the single most important measure to prevent infection).

Use of personal protective equipment (PPE) — gloves, gown, mask, eye protection — based on the anticipated exposure.

Safe injection practices (e.g., never recap needles, use a new needle for each patient).

Respiratory hygiene/cough etiquette (e.g., mask patients who are coughing).

Proper handling of contaminated equipment and linens.

Transmission-Based Precautions: These are additional precautions used for patients known or suspected to be infected with highly transmissible pathogens.

Contact Precautions: For infections spread by direct or indirect contact (e.g., MRSA, C. diff). Use gloves and a gown.

Droplet Precautions: For infections spread by large respiratory droplets (>5 microns) (e.g., influenza, pertussis). Use a surgical mask within 3 feet of the patient.

Airborne Precautions: For infections spread by small airborne particles (<5 microns) (e.g., tuberculosis, measles, chickenpox). Use an N95 respirator or higher, and place the patient in a negative pressure isolation room.

OSHA Bloodborne Pathogens Standard: This federal regulation requires employers to protect workers from occupational exposure to blood and other potentially infectious materials (OPIM). Key components include:

Exposure Control Plan: A written plan identifying at-risk employees and procedures.

Engineering Controls: Devices that isolate or remove the hazard (e.g., sharps containers, safety-engineered needles).

Work Practice Controls: Rules for how tasks are performed (e.g., no recapping needles, washing hands after glove removal).

PPE: Provided at no cost to the employee.

Hepatitis B Vaccination: Offered free of charge to at-risk employees.

Post-exposure Evaluation: A confidential medical evaluation and follow-up after a needlestick or other exposure incident.

CLIA-Waived Testing: The Clinical Laboratory Improvement Amendments (CLIA) categorize lab tests based on complexity. Waived tests are simple tests with a low risk of error (e.g., urine pregnancy tests, blood glucose monitoring, rapid strep tests). They are approved for use in the physician's office setting. The MA must follow the manufacturer's instructions exactly, perform quality control checks as required, and document all results.

Common Exam Traps

Students frequently miss questions on this content due to subtle but critical errors. Here are the classic traps:

111.The "Thumb" Pulse Trap: You must use your index and middle fingers to palpate a pulse. Using your thumb is a classic wrong answer because the thumb has its own pulse, which can be confused with the patient's.

112.The "Cuff Size" Trap: A blood pressure cuff that is too small will produce a falsely high reading, and a cuff that is too large will produce a falsely low reading. Students often reverse this. Remember: "Small = High" (think of squeezing a small cuff too tightly).

113.The "Ear Pull" Trap: For a tympanic temperature, you pull the ear pinna up and back for an adult and down and back for a child under 3. Students often mix these up. Remember: "Up for adults, Down for kids."

114.The "Sterile Field" Trap: The 1-inch border around the edge of a sterile drape is considered non-sterile. Also, never turn your back on a sterile field. A common wrong answer is that the entire drape is sterile.

115.The "Consent" Trap: The medical assistant witnesses the signature on the informed consent form. The provider is responsible for explaining the procedure and obtaining the consent. Never choose an answer where the MA explains the risks and benefits.

116.The "Respiration" Trap: You must count respirations without telling the patient you are doing so. If you tell them, they will consciously alter their breathing rate, giving you a false reading.

117.The "Order of Vital Signs" Trap: The correct order is typically Temperature, Pulse, Respiration, Blood Pressure (TPR & BP). You count respirations immediately after the pulse, keeping your fingers on the wrist, so the patient does not know you are counting.

118.The "Airborne vs. Droplet" Trap: Airborne precautions (TB, measles) require an N95 respirator and a negative pressure room. Droplet precautions (flu, whooping cough) require a surgical mask. Students often confuse which mask goes with which precaution.

119.The "Trendelenburg" Trap: Trendelenburg is feet elevated, head down. Students often confuse it with Reverse Trendelenburg (head up, feet down). Think of the "Trend" of the bed going down.

120.The "Normal BP" Trap: The AHA defines normal BP as < 120/80 mmHg. A reading of 120–129/<80 is now classified as Elevated, not normal. Students often choose 120/80 as "normal," which is incorrect per current guidelines.